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CCA Exam

CCA Exam Prep

Question	Answer
Explain the four major attributes of ICD-10-PCS codes.	1. Completeness: Every unique procedure has a code. 2. Expandability: New procedures can be easily added. 3. Multiaxial Structure: Seven characters describe different aspects of the procedure. 4. Standardized Terminology: Consistent and clear definitio
Explain the purpose of an encounter form/superbill.	An encounter form, or superbill, serves to: 1. Document services provided. 2. Bill using diagnosis and procedure codes. 3. Communicate with insurance for reimbursement. 4. Inform patients about their treatments.
Briefly describe the layout of the ICD-10-PCS table.	Tables: Organized by the first three characters of the code. Rows and Columns: Provide values for characters 4-7. Index: Helps find the right table based on procedure terms.
Discuss the structure of the ICD-10-CM alphabetic index.	Diseases and Injuries: Lists conditions alphabetically with codes. External Causes: Codes for accidents and exposures. Neoplasms Table: Classifies tumors by behavior and location. Drugs and Chemicals Table: Codes for poisoning and adverse effects.
Provide a brief overview of the CPT book.	The Current Procedural Terminology (CPT) book was originally published in 1966. It is used to assign codes for procedures and/or services provided by a physician in his/her office, or provided in an outpatient setting such as a surgery center. It's upda
Explain how the E/M section of the CPT code book is divided into categories.	he E/M section of the CPT code book is divided into categories based on service type and location: Office or Outpatient Services Hospital Inpatient Services Emergency Department Services Consultations Nursing Facility Services Home or Residence Serv
Identify the 6 root operations that always involve a device.	Insertion: Putting in a non-biological device. Replacement: Putting in a device that replaces a body part. Supplement: Adding a device to reinforce or augment a body part. Change: Exchanging a device without cutting or puncturing. Removal: Taking out
Explain whether or not it is appropriate to code specificity from ancillary reports for inpatient accounts.	Ancillary services typically refer to diagnostic services that originate in radiology and pathology. These services are provided by radiologists and pathologists, who are physicians. Therefore, it would seem that it would be appropriate to code their serv
Discuss the use of official sources of truth when assigning ICD-10 codes.	With the implementation of ICD-10 in October 2015, dependence upon reference materials for proper coding guidance are more important than ever to a medical coder. To compound the new codes, new technologies also add a layer of complexity (e.g., CAC and NL
Describe the HIM professional's role pertaining to data integrity.	The integrity of data in a healthcare organization should not be solely the responsibility of Information Technology (IT). HIM should be an integral member of the healthcare organization's data governance team. HIM should play a leading role in the develo
Describe how to apply coding conventions when assigning codes.	Correct assignment of ICD-10-CM/PCS codes is contingent upon each coder's comprehension of the coding conventions. With the use of computer-assisted coding and/or encoders as well as just having the basic knowledge of the conventions, most coders do not r
Discuss the purpose of following inpatient coding guidelines. Visit mometrix.com/academy for a related video. Enter video code: 412009	The ICD-10-CM and ICD-10-PCS official guidelines for coding and reporting are provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) primarily as companion documents to the ICD-10 coding books
Explain the process of abstracting information from medical records.	Abstracting is the process of gleaning pertinent information from the medical record upon patient discharge. For healthcare entities still using paper records, data can be collected in two ways: either by manually completing a paper abstract or by manuall
Discuss when it might be appropriate to browse the Internet for references applicable to coding situations.	Some of the most common coding references used by coders are available through an encoder or a computer-assisted coding (CAC) software program. However, there are times when these references do not address the current coding scenario. For example, a compl
Summarize the history of the development of the International Classification of Diseases (ICD).	The development of the International Classification of Diseases (ICD) can be traced back to the 16th century where evidence exists of death records kept by London parishes. Substantial progress began to be made with classification systems, however, in 189
Explain the importance of supporting assigned codes with reliable reference sources.	The use of reliable reference sources in support of code assignments is an absolute necessity as a coder. Inevitably, denials of submitted claims will be received by a healthcare organization. In order to appeal a denial (e.g., RAC) and ultimately win the
Identify the types of medical coding classification systems in health care.	A medical coding classification system is defined as a system that captures clinical data for reporting and reimbursement purposes. Reporting clinical data assists in statistical analyses of diseases as well as lending to decision support systems. There a
Define clinical vocabulary.	A clinical vocabulary (also known as clinical nomenclature) is best described as a list of clinical terms and their definitions/meanings. The clinical vocabulary list will be formally recognized by the healthcare entity as a list of preferred medical term
Describe the process of ensuring healthcare data are meaningful and useful.	With healthcare initiatives focused upon quality, outcomes, and payment methodologies, it is a common practice for healthcare institutions to process their data so that they are meaningful; in other words, the purpose ultimately is to promote informed dec
Explain the function(s) of a data dictionary.	A data dictionary can be defined as a tool used by healthcare organizations for the purpose of ensuring accurate data collection. In order for data to be reliable and usable, all users and owners of the data must understand/interpret its meaning based upo
Describe the uniform data collection process.	Uniform Hospital Discharge Data Set (UHDDS) was established in 1974 by the US Department of Health and Human Services (HHS) for the purpose of establishing a minimum, common core data set. The data set is abstracted at the time of hospital discharge and t
Discuss the role of the HIM employee in the capture of accurate healthcare data.	HIM professionals are essential team players in the capture of accurate healthcare data. A collaborative effort between HIM professionals and information technologists (IT) is key to the process of managing electronic information. HIM professionals may be
Explain the benefits of collecting accurate healthcare data.	Some benefits of capturing accurate healthcare data include: improving patients' quality of care identifying disparities in the delivery of health care enhancing healthcare research • identifying disease trends that aid providers in resource management an
Discuss how to determine the level of service of an outpatient E/M based on time, and list the proposed time range for new and established outpatient E/M services (new patient E/M: 99202-99205, established patient E/M: 99211-99215).
	CPT defines a new patient as one who has not received care from a provider or other qualified healthcare professional within the same practice in the exact same specialty and subspecialty within the past 3 years. An established patient is one who has prev
Explain the meaning of the principal diagnosis.	The principal (PDX) is one of the most important code assignments a coder can select. In many instances, the PDX will be the "driver" behind the diagnosis-related group (DRG) (also known as "disease groupings") selection. Of course, secondary diagnoses (S
Explain the number and complexity of problem (s) addressed in the medical decision-making risk table.	When determining the four types of medical decision making, the number and complexity of problems) addressed should be considered first. Simply listing a diagnosis in the assessment, stating that a different physician and /or practice is evaluating it, an
Discuss what modifiers are and why they are used.	Modifiers are two-digit alphabetical, numerical, or alphanumerical characters that are appended to CPT and HCPCS Il codes. They are used indicate anatomical locations (i.e., LT indicates the left side), the health status of a patient (i.e., P1 represents
Describe the difference between modifier 25 and modifier 59.	The main difference between modifiers 25 and 59 are the procedural codes that they are attached to. Modifier 25 is used to report a "significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare
Explain the amount and/or complexity of data reviewed in the medical decision-making risk table.	When determining the four types of medical decision making, the amount and/or complexity of data reviewed should be considered second. The data are divided into three subcategories: Each individual test, document, or independent historian(s) Independent i
Discuss the purpose of re-sequencing codes in ICD-10.	AHIMA has an established Standards of Ethical Coding that coders are expected to follow. The standards emphasize that all healthcare data elements (e.g., diagnosis codes, procedure codes) must be reported completely and accurately and supported by healthc
Discuss what is and what is not included in the leveling of an outpatient E/M based on time.	Leveling an E/M based on time includes total face-to-face time spent on the care of the patient on the date of the primary service, such as performing a medically appropriate physical examination and history, counseling and/or educating the patient, famil
List the four types of medical decision making and the three elements it is made of.	The four types of medical decision making are straightforward, low complexity, moderate complexity, and high complexity. In order to determine which of the four types a medical note would constitute, three elements would need to be considered: 1) number a
Explain how to properly sequence ICD-10-CM codes for an inpatient.	The sequencing of diagnostic codes is key to accurate diagnosis-related group (DRG) assignment. Code sequencing drives the selection of the principal diagnosis, which is really the most important code assignment a coder will make. Of course, the principal
Describe Medicare's requirements for E/M services.	Medicare funds are protected under the Social Security Act. Section 1862(a)(1)(A) of the Act stipulates that Medicare will only reimburse for services that are reasonable and necessary. It is the healthcare provider's responsibility to bill the appropriat
Contrast professional component and technical component of a CPT code.	The differences between the professional component of a service and the technical component of the same service can be a confusing topic for coders to understand. As a result, sometimes healthcare entities will establish their charges for technical servic
Explain the process of using the ICD-10-PCS index to locate a procedure.	A coder should first reference the ICD-10-PCS index to begin the process of locating the most appropriate code for the procedure performed. The procedural codes are organized in the index based upon the general type of procedure (e.g., excision, dilation,
Describe the code structure of an ICD-10-CM code.	ICD-10-CM codes contain anywhere from 3 to 7 characters, with a decimal after the third character. The first character of the ICD-10-CM code will always be one of the following alphabetic letters: A-T and V-Z. Note, the letter "U" is not used because it h
Explain how "time" is relevant to CPT code selection.	Time is an important factor when considering the assignment of some CPT codes. Time is understood to be the amount of time when the healthcare provider is face-to-face with the patient (e.g., evaluation and management services). It is also important to un
Discuss the purpose of following outpatient coding guidelines.	The Current Procedural Terminology (CPT) code set is the most widely accepted nomenclature for the reporting of physician procedures and services. It is endorsed by the HHS as the nationally accepted coding standard. Each section of the CPT code book incl
Describe the four different types of examinations when assigning E/M codes.	Explanation of each exam is as follows: Type of Exam Extent of Exam Assessment Results Problem-focused Limited to an affected body part or organ 1 to 5 structures or functions of the body part/organ Expanded problem-focused Limited to an affected body par
Describe the organization of the Surgery section in the CPT book.	The CPT Surgery section of the CPT book is organized according to body systems (e.g., General, Cardiovascular system, Respiratory system, Nervous system). Each of the surgical categories is further subdivided according to organs, anatomical sites, and typ
Explain the types of punctuation marks used in ICD- 10-CM coding.	The following punctuation marks are used throughout the ICD- 10-CM code book: parentheses, brackets, and colons. They are used in both the Alphabetic Index as well as the Tabular List. Parentheses are used to enclose supplementary words associated with a
Explain the purpose of modifiers.	Modifiers are used quite frequently with CPT codes. Their purpose is to indicate that the procedure has been altered in some way from the usual procedural process. With the application of modifiers, the assignment of extra separate procedure codes is avoi
If an intended procedure is discontinued, determine how the ICD-10-PCS coding is assigned.	In some instances, an operative procedure is discontinued for various reasons. When this occurs, the coder must determine to what extent the procedure was conducted. Once this is determined, the coder should code the procedure to the appropriate root oper
Discuss the specific services included in a CPT surgical code.	There are certain services that are always bundled into the CPT surgical code in addition to the actual operation. Since the services are bundled into one CPT surgical code, they are not "unbundled," meaning they are not coded separately. The following se
Describe the two ICD-10-CM coding abbreviations seen in the alphabetic index.	In the ICD-10-CM code book, there are two abbreviations used as conventions that affect code assignment. They are: Not Elsewhere Classified (NEC) and Not Otherwise Specified (NOS). Not Elsewhere Classified means when a specific code is not available for a
Describe the documentation requirements for examinations when assigning E/M codes.	When a physician selects the physical examination component of an evaluation and management (E/M) code, he/she must provide documentation to support that selection. To aid in this selection process, the AMA has outlined the documentation requirements for
Describe the services included in anesthesia CPT codes.	CPT codes not only exist for procedural codes, but they also are available for anesthesia services. The code range for these codes is 00100-01999. Anesthesia services are provided by an anesthesiologist or by a certified registered nurse anesthetist under
Describe the ICD-10-PCS format.	ICD-10-PCS is formatted in three sections: Tables, Index, and List of Codes. The Index is an alphabetic listing of procedures/operations. Codes are organized in the Index according to the general type of procedure. Of note, the Index only provides the fir
Describe the difference between modifier 52 and modifier 53.	Modifier 52 is appended on surgical procedures for which anesthesia is not required, to indicate that a procedure was partially reduced or eliminated after the patient was prepared and /or brought into the surgical room. The provider may expect to partial
In ICD-10-PCS coding, explain how "upper" and "lower" body parts are determined.	In ICD-10-PCS coding, in some scenarios, a coder will encounter documentation referring to "upper" or "lower" body parts. For example, the documentation may refer to upper or lower arteries or veins. When the terms "upper" or "lower" are used in reference
Determine the level of medical decision making in the following scenario: a 78-year-old man is seen in the office for a medication renewal. He has a history of type 2 diabetes and hypertension. He has been compliant with medication and has no complaints.	The level of medical decision making for this scenario is moderate. The patient has type 2 diabetes and hypertension, which are two of the most common chronic health conditions. Other common illnesses that are considered to be chronic include asthma, hear
Explain the differences among the problem-focused history, expanded problem-focused history, detailed history, and comprehensive history used for inpatient (99221-99233, 99234-99236), emergency (99281- 99285), observation (99218-99220), and nursing facili	There are three elements that collectively contribute to the history component of an inpatient, emergency, observation, and nursing facility care E/M: History of present illness (HPI) Review of systems (ROS) Past medical, family, and /or social history (P
Explain the differences of the 1995 and 1997 E/M guidelines when evaluating the exam portion of a medical record.	According to the E/M guidelines issued in 1995, a provider or other healthcare professional could choose to level their examination based on a how many body areas they evaluated on a patient or based on the number of organ systems. Body areas include, but
Describe the difference between modifier 58 and modifier 78.	Modifier 58 is used on a staged or related procedure performed by the same physician during the 10- or 90-day postoperative period. Keywords when reporting modifier 58 would include planned, anticipated, or staged. Modifier 78 is used on an unplanned proc
Discuss how the history and exam of a patient contribute to the level of an outpatient E/M (99202-99205, 99212-99215).	Before January 1, 2021, the history and physical examination of a patient were components that contributed to the leveling of an outpatient E/M. Now, CPT guidelines only require that a "medically appropriate history and/or examination" are obtained from t
Explain the risk of complications and/or morbidity or mortality in the medical decision-making risk table.	The risk of complications and/or morbidity or mortality is the final element to be reviewed when determining the four types of medical decision making. In the context of MDM, the level of risk is based on the consequences of the problem, when appropriatel
Elaborate on this adage: "If it isn't documented, it hasn't been done.”	The statement, "If it isn't documented, it hasn't been done," has been a long-standing adage well known to health information professionals. Healthcare provider documentation of diagnoses and treatment rendered is the key to preventing denials, winning ap
Explain the process of selecting a CPT code from the CPT Index.	In order to select an appropriate CPT procedural code from the CPT code book, the coder should access the index found the back of the code book. The alphabetic index is organized according to four categories of main entries. The main entries can be locate
Discuss the structure of the ICD-10-CM tabular list.	The key to understanding the ICD-10-CM tabular list is to be aware of how it is categorized and subcategorized. The first principle to understand is that the list is divided into 21 chapters. The following flowchart depicts the breakdown of chapter 1 as a
Contrast the definitions of new and established patients when assigning E/M codes.	In order to assign the correct evaluation and management (E/M) code, it is necessary to understand the difference between a new patient and an established patient. The difference is easy to understand because essentially it is based on a time frame of 3 y
Explain the coding guideline for assignment of the first-listed condition (diagnosis) for outpatient stays.	When assigning diagnostic codes for an outpatient encounter, a "principal diagnosis" would not be assigned for outpatient services because principal diagnosis refers solely to an inpatient admission. Rather, for outpatient services, the reason for the enc
Discuss the steps involved with assignment of a POA indicator for a combination code that identifies both the chronic condition and the acute exacerbation.	Present on Admission (POA) indicators are a reporting requirement for healthcare providers. The Deficit Reduction Act of 2005 mandated that providers report whether diseases were present on admission or not. The intent of the indicators is to differentiat
Describe the code symbols used in the CPT codebook.	Code symbols are used in the CPT code book to facilitate quick understanding. They primarily represent additions, deletions, and revisions. A quick reference table of the symbols and their meanings are noted here: Symbol Meaning Bullet New procedure cod
Identify the 5 root operations wherein the objective is to pull out/off all or a portion of a body part.	Root Operation Purpose of the Procedure Site of Procedure Excision Cut out or off Portion of a body part Resection Cut out or off Entire body part Detachment Cut out or off Extremities only; exclusive to amputations Destruction Eradicate/Destroy Body part
When a biopsy is followed by more definitive treatment, explain how to determine the appropriate code assignment.	When a biopsy of a site leads to more definitive treatment (such as excision of the diseased site), both the biopsy and the more definitive treatment are coded. A good example of this guideline is when a biopsy of the breast is positive for carcinoma, and
Discuss the purpose behind instructional notes in the alphabetic index and tabular list of ICD-10-CM.	The different types of notes are: inclusion notes, exclusion notes, code first notes, use additional code notes, and cross-reference notes (e.g., see, see also, and see condition). The inclusion notes are easy to identify because they are introduced with
Explain the coder's role regarding CPT code assignments.	When services are provided in a physician's office or clinic, the CPT code will be selected by the physician from an encounter form or superbill. The coder or biller is responsible for transferring the selected codes from the encounter form onto the insur
Discuss CMS's global surgery concept.	CMS has defined the global surgery concept (also known as a surgical package) as a range of services included in an operation. From a reimbursement perspective, the surgical package is understood to be bundled under the appropriate corresponding CPT proce
Describe the 7 characters for medical and surgical procedures.	Medical and surgical procedural codes are composed of 7 characters. The characters and their meaning follow. The first character represents 4 different sections: 0 - Med/Surg; 1 - Obstetrics; 2 - Placement; and, 3 - Administration. (The majority of proced
Describe the purpose of an encoder.	An encoder is an electronic tool that receives diagnostic or procedural data manually entered by a coder, and then converts the data into a numerical code. An encoder is a logic-driven tool that prompts the coder through several choices/options until the
Explain the key elements of an EHR system for a physician's practice.	Many physician offices are migrating away from paper record systems to EHRs. Multiple EHR systems are available for purchase in today's market, so it is imperative that physician offices designate a work team and a strategic plan to select the best system
Identify the benefits of an electronic health record.	Use of an electronic health record (EHR) boasts many benefits. One of the most obvious benefits is the fact that any patient's health information may be accessed instantly by more than one user across innumerable organizations. In other words, it is avail
Discuss potential problems with CAC-assigned codes and the importance of validating those codes.	Computer-assisted coding (CAC) software does not diminish the role of a coder. Rather, the value of having the coder's knowledge and skills applied to the CAC process enhances the overall coding accuracy. In other words, coders will not be replaced by a m
Discuss the meaning of "CAC."	CAC software is a helpful aid to coders because it analyzes electronic health information for specific medical terms and phrases that correlate to numerical codes. CAC software uses natural language processing (NLP) to identify the terminology. CAC offers
Describe NLP processing as an integral part of CAC.	Natural Language Processing (NLP) is an integral and important part of computer-assisted coding (CAC). NLP technology has the capability to process text as well as data fields containing text into suggested ICD-10 codes. NLP technologies differ in how the
Briefly describe the basics of auditing code assignments.	Healthcare entities should never assume that computer-assisted coding (CAC) systems are 100% accurate. Therefore, it is imperative to implement a coding compliance program in which auditors review accounts on a daily basis. The volume of coded charts will
Explain how templates and prompts are used in EHRs.	Templates and prompts are tools used in the development of electronic health records (EHRs). They differ in their purpose with templates used to collect, present, and organize data elements, and prompts used to remind providers of required documentation.
Describe an electronic health record.	An electronic health record (EHR) is a digital version of patients' health information. EHRs provide the means to access patients' health information instantly and for more than one user at a time across multiple healthcare venues. While EHRs do contain t
Identify HIM roles and responsibilities in electronic medical record management.	Health Information Management (HIM) professionals are key to the successful adoption of an electronic health record (EHR). In fact, an HIM professional must be in a leadership position when it comes to ensuring that the EHR is legally compliant. The HiM p
Explain the types of coding reference materials available in an encoder.	An encoder is an electronic tool that receives diagnostic or procedural data manually entered by a coder, and then converts the data into a numerical code. An encoder is a logic-driven tool that prompts the coder through several choices/options until the
Describe the type of information contained within an electronic health record.	The healthcare information contained within an electronic health record (EHR) is similar to the information housed in a paper health record. Administrative and billing data, demographics, medical history, physical examination, diagnoses, procedures, medic
Discuss the elements of a top-ranked practice management system.	A practice management system is the software that runs the business side of a healthcare practice. It is usually separate from the electronic health record (EHR), which is the world where physicians primarily operate. The practice management system is the
Explain how the workflow of CAC occurs.	The daily workflow a coder might encounter using computer-assisted coding (CAC) could proceed as follows: • • Coder logs into the CAC system. Coder selects account to code from the coding queue. • CAC opens the electronic patient record for viewing throug
Identify potential problems with the utilization of CAC.	Computer-assisted coding (CAC) software/systems can be an excellent tool in the selection of accurate diagnostic and procedural codes supported by compliant documentation. However, CAC is not without its problems. CAC does not have the capability to decip
Describe the difference between pre-bill and retrospective coding audits.	A pre-bill coding audit is an audit that is conducted before the initial claim is ever submitted to the payer. The benefit to conducting a pre-bill audit is that errors are identified and corrected proactively, which prevents payment denials and/or paymen
Identify examples of common reports used for data analytics by HIM professionals and/or healthcare data analysts.	In the health information field, data analytics is a common daily task. Obtaining meaningful and relevant data is the primary objective. The following are examples of common data analytical reports generated by health information professionals: Calculatio
Define the master patient index.	The master patient index (MPI) is a data repository of all patients who have ever been admitted or treated at a healthcare organization. The MPI is the source of truth to reference when attempting to locate patient records. The American Hospital Associati
Define HIM's role in information governance.	Information governance (IG) for electronic health records (EHRs) cannot be ignored despite the challenges facing healthcare organizations of large volumes of data, duplicate data, and inaccurate data. Healthcare organizations must identify key stakeholder
Describe the purpose of qualitative analysis of medical records.	Qualitative analysis of medical records or health information is the process of identifying deficiencies pertaining to incomplete or inaccurate documentation. The HIM professional analyzing the documentation must understand disease processes in order to i
Explain HIE.	Health Information Exchange (HIE) refers to the electronic method of accessing and/or sharing patient health information (PHI) among healthcare providers as well as allowing patients to access their own information through secure web-based portals. The ca
Discuss the retention requirements for the patient index.	The master patient index (MPI) is a data repository of all patients who have ever been admitted or treated at a healthcare organization. The MPI may be manual or electronic system. For manual systems, the index cards containing the patient information may
Briefly discuss "Big Data."	Big data is referenced in this fashion for three reasons: • the sheer volume of data that is available the increasing frequency with which data are made available the many forms of data The volume of healthcare data has grown exponentially in the last few
Define semantic content of an EHR.	An electronic health record (EHR) is a record of a patient's healthcare journey composed of electronic documents from various electronic systems. Prior to the EHR era, health information was maintained in paper records. Upon a patient's discharge, the pap
Explain healthcare benchmarking.	Healthcare benchmarking is the process of analyzing data for the purpose of identifying strengths and weaknesses and then implementing practices that lead to superior performance. Benchmarking allows a healthcare entity to compare itself against other hea
Briefly discuss the benefits of HIE.	Health Information Exchange (HIE) refers to the electronic method of accessing and/or sharing patient health information (PHI) among healthcare providers as well as allowing patients to access their own information through secure web-based portals. The ma
Briefly explain meaningful use.	Pursuant to passage of the American Recovery and Reinvestment Act (ARRA) of 2009, an incentive program of monetary rewards for the adoption of Health Information Technology (HIT) and Electronic Health Record (EHR) systems was initiated. In addition to ado
Explain the medical record request process.	Health information must be kept confidential, and the healthcare world is regulated by laws and policies that require confidentiality. In order to access patient information, release of information processes must be followed by healthcare institutions to
Discuss the functionality of PivotTables and PivotCharts in Excel.	In Excel, PivotTables are an excellent tool to summarize data into categories and filter the data in various meaningful ways. An HIM analyst whose responsibility may be data collection and data comparison, will find that PivotTables make data collection a
Elaborate upon the management of patient identification.	Accurate and consistent patient identification is an absolute necessity in today's healthcare environment, especially with an emphasis upon patient safety. Without proper patient identification, the possibilities of medication administration errors or blo
Briefly explain how all information should be brought together to generate an electronic record.	An electronic record (EHR) is "assembled" through different means of capture: scanned paper documents, automatic feeds, and manual entry. Scanned paper documents or document imaging processes are necessary for paper documents to become a part of the EHR.
Identify types of data analysis tools.	In the healthcare marketplace, there are many data analytical software packages available for purchase. In Excel, PivotTables are an excellent tool to summarize data into categories and filter the data in various meaningful ways. Excel also offers the opt
Describe effective training for providers regarding health data, coding, and documentation standards.	Effective training platforms for hospital-affiliated providers should be conducted with the understanding that providers are interested in the patient-care perspective more so than the coding classification system. Physician education sessions should be p
Explain the purpose of the ONC for Health Information Technology.	The Office of the National Coordinator for Health Information Technology (ONC) is responsible for leading the movement to promote health information exchange (HIE). HIE is growing in popularity among healthcare providers. As a result, the ONC has establis
Explain the purpose of data abstraction.	The purpose of data abstraction is to extract pertinent information from the medical record for multiple reasons. Standard data that should always be abstracted for statistical reasons (e.g., case mix index), reporting reasons, and compliance reasons are
Outline the components of a medical record.	Although there are no requirements for what should be included in a medical record, there are several components that are recommended in order for a record to be considered complete. The first component is a personal identification number that, when used,
Define health data standards.	Data standardization can be defined as the standardization of data elements (basic units of information that are unique with distinct values). Health data should be standardized in terms of defining what data to collect, deciding how the data will be repr
Discuss the three key forms of HIE.	Health Information Exchange (HIE) refers to the electronic method of accessing and/or sharing patient health information (PHI) among healthcare providers as well as allowing patients to access their own information through secure web-based portals. There
Discuss the components of a qualitative analysis.	Qualitative analysis of medical records or health information is the process of identifying deficiencies pertaining to incomplete or inaccurate documentation. The components of qualitative analysis should include review of the following: Diagnostic statem
Discuss what should be included in a physician's clinical notes.	What a physician documents in their clinical notes often has a direct impact on the continuity and quality of care provided to a patient, especially when multiple physicians are involved. Additionally, an insurance company can choose to deny or recoup pay
Explain best practices for data validation.	Data in raw form are not as meaningful as data that have been analyzed and processed to create pertinent information for a healthcare organization. However, before data analysis can occur, there are best practices to implement. Some examples include: Dete
Describe the purpose of quantitative analysis of medical records.	Quantitative analysis of medical records or EHR information is performed by health information personnel. The purpose of quantitative analysis is to identify documentation areas that are incomplete or inaccurate. Examples of documentation deficiencies may
Discuss the IGPHC.	Information Governance Principles of Healthcare (IGPHC) are adopted by healthcare entities to emphasize their commitment to managing complete and accurate information, which improves the quality of patient care, promotes operational efficiency, reduces ri
Discuss the components of a quantitative analysis.	Quantitative analysis of medical records or EHR information is the process of identifying documentation deficiencies. The identified deficiencies must be resolved by the healthcare provider within a time frame of up to 30 days depending upon the type of d
Discuss ways to retrieve medical information from an archived state.	As patient health information ages and electronic storage space becomes limited, it is necessary for healthcare institutions to archive the information in accordance with federal and state regulatory retention guidance. Once the data are archived, they ca
Explain how a healthcare organization might go about conducting data mining.	In order to retrieve medical record or health information data, it is beneficial for a healthcare provider to implement a robust data mining program. For data mining to yield reliable results, the best practice would be for a healthcare entity to have all
Explain payer matching.	When a claim is submitted to an insurance carrier by the healthcare entity, the claim will be scrubbed, which means it will be checked for errors. Once any identified errors are corrected, the claim will be forwarded onto the payer for review. In order to
Explain how to locate an NCD/LCD online.	CMS.gov/Medicare-coverage-database is one of the quickest ways to locate a national coverage determination (NCD) or a local coverage determination (LCD). All NCDs and LCDs, regardless of status (e.g., active, retired, future, or proposed) are maintained i
Describe the two forms used for submitting claims.	In healthcare, there are two forms used for claims submission. They are the UB-04 and the CMS-1500. The UB-04 is a universal claim form that is used by hospitals, critical access hospitals, hospices, home health agencies, outpatient rehab facilities, end-
Identify the most common types of claim denials.	Insurance claim denials are an expected occurrence in healthcare revenue cycle management. Some of the most common claim denials and an explanation are as follows: Type of Denial Explanation Technical Denials may occur because of a problem with claims pro
Explain how proper training and up-to-date resources can prevent denials.	One of the most critical steps a healthcare provider can conduct is to ensure that all revenue cycle resources are current. This requires updating of resources at least annually, and for some resources (e.g., chargemaster), updating may be more frequent.
Discuss how risk adjustment coding affects the revenue cycle, and define risk adjustment factors.	Risk adjustment coding has a direct impact on the revenue cycle for multiple reasons. The first reason has to do with a physician's documentation. If a physician thoroughly documents a patient's chronic health condition(s) and the impact it has on their h
Define revenue cycle management.	Revenue cycle management in healthcare is a three-part process. It involves management of the healthcare institution's claims processing, payment processing, and revenue generation. The revenue cycle begins at the point of determining patient eligibility,
Explain the purpose of the National Correct Coding Initiative (NCCI).	The NNCCI was developed by CMS for the purpose of encouraging correct coding methodologies nationwide. NCCI is applicable to Part B claims only. Healthcare entities can assess their coding accuracy prior to submitting a Part B claim and thus potentially p
Discuss the meaning and purpose of IPPS.	The inpatient prospective payment system (IPPS) is Medicare's payment system for acute care inpatient hospital stays, specifically Medicare Severity Diagnosis Related Groups (MS-DRGs). MS-DRGs have been around since 2007, and provide higher reimbursement
Discuss the purpose of identifying HACs.	A hospital-acquired condition (HAC) is an unfavorable condition (e.g., an infection, development of a decubitus ulcer) that occurs during the hospitalization and adversely affects the patient's health and course of treatment. Another way to understand HAC
Discuss ways to generate clean claims, thus reducing the number of denials.	For a healthcare entity to have a 100% clean claim rate would be nothing short of a miracle. The reality is there are many challenges with submitting clean claims; however, there are strategies to follow that can reduce the number of "dirty" claims and th
Explain the importance of having physician query policies.	Physician queries are an integral part of clinical documentation improvement (CDI) programs in healthcare institutions today. In order to standardize methods for physician query processes, query policies are recommended. Effective policies should establis
Identify modifiers that are allowed with the NCCI edits and when they are allowed.	Modifiers may be appended to a CPT code so that a CCI edit can be bypassed. Bypassing an edit, however, should only be done if the clinical documentation supports the addition of the modifier. The NCCI edit table will indicate whether the application of a
Discuss the types of financial reports that are relevant to both coding and patient financial services.	Effective communication between the coding department and patient financial services (PFS) is essential to revenue cycle operations in a healthcare institution. There are primarily three areas wherein the two departments must collaborate. One of the prima
Briefly explain the life cycle of a claim.	The life cycle of a claim begins with the creation of a patient encounter, whether through the emergency department, outpatient services, or an inpatient admission. Services are then rendered for the patient, and charges associated with the services are e
Explain how combination coding affects sequencing of codes.	Combination codes are required for some disease processes in ICD-10-CM coding. Combination codes are recognized as a single code that represents two disease processes. They can also represent one diagnosis with an associated symptom, or one diagnosis with
Describe the structure of APCs.	Ambulatory Payment Classifications, or APCs, is Medicare's payment methodology for outpatient services. One could describe it as the "DRG" system for outpatient services. APCs are an outpatient prospective payment system (OPPS) for hospitals only. They ha
Identify and explain the Medicare code edits for ICD- 10-PCS codes.	For ICD-10-CM/PCS codes, Medicare has code edits in place to assist with coding accuracy. Some of the Medicare Code Edits (MCE) are as follows: Invalid diagnosis or procedure code - Each code is compared against a table of valid codes, and if a submitted
Discuss the meaning of medical necessity.	The basic concept of medical necessity is that invasive procedures and diagnostic studies should only be performed when they are medically necessary. Medical necessity is the deciding factor as to whether or not a payer will reimburse the healthcare entit
Discuss the consequences of filing a claim with falsified information.	The most obvious consequence of filing a claim with incorrect or falsified information would be rejection of the claim and/or denial of the payment by the insurance payer. On a more serious note, individuals and entities can be penalized for filing false
Describe tools for tracking denials.	Part of the revenue cycle management process is to track insurance payer denials and trend the reasons for the denials so that future denials can be prevented. Healthcare entities should use certain tools for the purpose of tracking denials. A claim denia
Determine when it is appropriate to resubmit a claim to the payer.	When a claim is rejected by Medicare, the healthcare provider may decide to resubmit the claim for reconsideration. The claim, of course, must be revised to exclude any identified errors before resubmission. The provider must also check Medicare's Common
Define what it means to unbundle CPT codes.	Unbundling occurs when certain procedures that should be reported together under one code are reported separately. Although this can increase the provider's revenue, it is illegal. For example, a lipid blood panel (CPT code 80061) consists of the followin
Identify ways to promote clinical documentation improvement opportunities with physicians.	Physicians are sometimes resistant when it comes to improving their documentation, primarily because of the belief that it entails more work for them to complete. However, there are effective ways to promote clinical documentation improvement among physic
Explain the purpose of linking diagnoses and CPT codes.	It is important to remember that CPT procedural codes must be linked to a corresponding ICD-10-CM diagnosis code. Failure to link the two codes will most likely result in a medical necessity denial of the claim by the payer. The ICD-10-CM code links the d
Discuss what hospital services are covered under APC payment.	Ambulatory Payment Classification (APC) payments apply to services rendered in an outpatient setting. These outpatient services may be rendered in an outpatient surgery setting, outpatient clinic setting, emergency departments, and/or observation services
Explain how a coder might be involved in resolving NCCI edits.	Certified coders, who are knowledgeable in proper coding methodologies, should be involved in the workflow process of reconciling any National Correct Coding Initiative (NCCI) edits. An NCCI edit is an indication that at least one code in the code pair is
Briefly explain an ABN.	Advance beneficiary notice (ABN) (of Noncoverage) is a tool used to notify traditional Medicare beneficiaries that Medicare will most likely deny payment of certain services. This notice allows the beneficiary the opportunity to make an informed decision
Explain how to submit a claim form for non-covered charges.	The CMS has specific instructions on how to file claims for non-covered charges. The Medicare beneficiary must have been notified that the services would not be paid by Medicare through the process of issuing an advance beneficiary notice (ABN). The ABN a
Explain the process of adjudication.	Adjudication in the revenue cycle management world is a process in which submitted claims are evaluated by the payer for validity and determination of whether payment will be rendered or not. It is during the adjudication process that a claim will either
Explain adjustments and redeterminations.	A claim adjustment means a healthcare provider has made the necessary corrections to a denied original claim, and with resubmission of the claim to the insurance carrier, the provider is canceling the original claim and replacing it with the corrected cla
Discuss how to determine if two or more CPT codes should be bundled.	The National Correct Coding Initiative (NCCI) edits were created by CMS as an aid to physicians, suppliers, and hospitals to reduce incorrect payments that result from improper coding, such as unbundled procedures. Each CPT code in the NCCI edits is locat
Provide an example of when it would be appropriate to re-sequence ICD-10-CM codes for optimal reimbursement.	When assigning ICD-10-CM codes for an inpatient encounter, there are occasions wherein it would be appropriate to re-sequence the codes in order to obtain optimal reimbursement. This usually occurs when the ICD-10 Official Coding Guideline for selection o
Explain the Medicare appeals process for claim denials.	When a healthcare provider disagrees with Medicare's payment decision, an appeal may be pursued. The appeal process can be lengthy as there are five levels of appeal. Level 1 involves a redetermination process by the company who processes claims for Medic
Discuss the number of CPT codes that may be linked to one diagnosis code.	Every CPT procedural code must be linked to a corresponding diagnosis code. The selected diagnosis code should support the medical necessity of the procedure. To know if the diagnosis code is supportive, one would need to reference CMS's national coverage
Explain whether or not ICD-10-CM codes affect APC payments.	ICD-10-CM codes do not affect APC payments in a direct manner. The diagnostic codes are not used to determine facility reimbursement. They are, however, important from a medical necessity standpoint, and in that way, they indirectly affect APC payments. I
Explain the purpose of an NCD and LCD.	National coverage determinations (NCDs) are published by Medicare for the purpose of noting what services or procedures will be covered by Medicare. An NCD is mandated at the national level for all fiscal intermediaries and Medicare Administrative Contrac
Explain how packaging of items and services affects APC payments.	Packaging of items and services in the Outpatient Prospective Payment System (OPPS) is commonly noted in Ambulatory Payment Classifications (APCs). Within each APC, at a minimum, the following services are packaged or included: • Supplies • Ancillary serv
Describe the structure of DRGs.	Diagnosis-related groups (DRGs) represent categories of patients who are medically related based upon their diagnoses/conditions and treatment of the diagnoses/conditions. Another factor of similarity between the categories is the lengths of inpatient sta
Discuss DRG weights and their impact upon reimbursement.	Diagnosis-related groups, or DRGs, as they are better known, are a group of related conditions/diseases that are a component of the inpatient prospective payment system (IPPS). The IPPS is a payment system set forth by the Social Security Act for Medicare
Define HCC.	HCC (Hierarchical Condition Category) is a payment model used by Medicare Advantage Plans (also known as Medicare Part C) and some other commercial managed care plans to predict the future costs of a patient over time. Estimated health costs are based on
Determine when an appeal in a medical practice is appropriate.	When a medical practice or physician's office decides to appeal medical claims), it is always beneficial to consider the costs involved. Of course, the best way to manage costs is to ensure that a claim is clean or valid before it is billed to the payer,
Explain the types of payment models for which the coding and financial services' departments must be familiar.	Obtaining reimbursement for healthcare services is a complex process. Therefore, it is imperative that the coding department and the financial services' (or revenue cycle) department communicate efficiently and effectively in order to obtain maximum reimb
Describe coordination of benefits.	When an individual is covered by more than one insurance plan, guidelines pertaining to coordination of benefits (COB) will instruct healthcare providers as to which insurance carrier to bill as the primary payer and which insurance carriers) to bill as t
Discuss how CMS creates an NCD.	The Centers for Medicare and Medicaid Services (CMS) develops national coverage determinations (NCDs) when there is a need to provide coverage for new healthcare technologies or procedures or when there is a need to consider an existing procedure as being
Describe how to locate APC payment tables on CMS.gov.	Ambulatory Payment Classifications (APCs) are updated annually. The updated payment rates are posted for general public knowledge on the CMS.gov site. To locate the table, there are several steps to follow. They are: • • • Navigate to CMS.gov Select the M
Describe the structure of MDCs.	Major diagnostic categories (MDCs) were established for the purpose of categorizing patients according to diseases and disorders by body system. MDCs are either medically or surgically structured. Medical MDCs are further divided into diagnosis-related gr
Explain the purpose of the "present on admission" (POA) indicator.	The purpose of the present on admission (POA) indicator is to indicate which conditions are present at admission and which conditions develop during an Inpatient admisston. One of the following four POA Indicators must be reported with all codest Y - yes,
Briefly describe governmental audits.	Federal auditors have the authority to review Medicare and Medicaid claims submitted by providers. Some of federal government audit entities are Medicare Recovery Audit Contractor (RAC), Office of Inspector General (OIG), Zone Program Integrity Contractor
Explain the purpose of a Chargemaster.	A hospital has a database that contains all charges for services rendered. This database is known as the chargemaster or charge description master (CDM). The CDM is the core of a hospital's revenue cycle. Each hospital department is responsible for enteri
Briefly discuss the implementation of ICD-10 coding changes that occurred on October 1, 2015.	October 1, 2015 is the date well known to health information management (HIM) professionals. It was the much anticipated time when the ninth edition of the International Classification of Diseases (ICD) was finally retired, and the ICD-10 coding system wa
Provide examples of a leading query.	Leading provider/physician queries are not acceptable in healthcare. The following are examples of inappropriate leading queries: • A query that provides the physician with options that only lead to additional reimbursement. A query that does not contain
Explain when it is appropriate to initiate a physician query.	Initiation of a physician query is appropriate when documentation within the medical record fails to provide the necessary information needed by the coder to make an informed decision about a code assignment Issues such as legibility, completeness, clarit
Explain the meaning of coding compliance.	Coding compliance is an important function of healthcare operations secondary to federal regulations. Code assignments must be supported by clinical documentation in order to avoid denials by payers and/or appeal their decisions. Discrepancies between cod
Briefly explain why healthcare providers must now be more specific with their documentation practices.	With the implementation of ICD-10 coding classification system, the expectation for more in-depth documentation became a reality. ICD-10 brought about major changes in the areas of: classification axes, laterality, obstetrical trimester specificity, expan
Discuss the process of updating a charge ticket in a physician's office.	In order to prevent payer denials, a physician's office should update a charge ticket or encounter form annually (at a minimum) or as significant coding/charging changes occur. By proactively making the necessary changes to a charge ticket, denials on the
Explain the importance of using the following resources when researching coding changes: Coding Clinic, CPT Assistant, and 3M Nosology.	An experienced coder understands the importance of accessing reliable resources for compliant coding, Coding Clinic, CPT Assistant, and 3M Nosology are reliable resources frequently referenced by seasoned coders. The American Hospital Association (AHA) pu
Explain the meaning of clinical indicators.	Compliant coding is dependent on the accuracy and completeness of documentation. In some cases, healthcare documentation is not sufficient to support code assignments, and in those cases, physician queries are necessary. Queries must contain certain eleme
Discuss AHIMA's Standards of Ethical Coding.	The American Health Information Management Association (AHIMA) has issued standards pertaining to ethical coding. The standards reflect the expectations for professional coding conduct in diagnostic and procedural coding as well as abstracting of health i
Explain the steps necessary to prepare for external audits.	Hospitals experience audits from external agencies on a regular basis. The external auditors may be representatives of various federal agencies (e.g., Office of Inspector General, Department of Justice, Medicare Administrative Contractors). They may also
Identify physician documentation vulnerabilities.	Physician/Provider documentation always has room for improvement, especially in a world of constantly changing healthcare regulations. The Office of Inspector General (OIG) is well aware of documentation vulnerabilities and publish these annually in their
Explain the dynamics of an EMTALA audit.	EMTALA is the acronym for Emergency Medical Treatment and Labor Act. Congress enacted EMTALA in 1986 to ensure that all people would have access to emergency services regardless of the individual's ability to pay. This law mandates hospitals to provide st
Define the types of standards to establish to ensure ethical coding.	Certified coders and/or clinical documentation improvement specialist (CDIS) are obligated to follow the ethical standards published by the American Health Information Management Association (AHIMA). Many healthcare organizations implement steps to ensure
Explain the meaning of a leading query and why it is unacceptable.	A leading query can be defined as one that is not supported by the clinical elements contained within the medical record, or it can be defined as a query that directs a healthcare provider to a specific diagnosis or procedure. Leading a provider to a spec
Explain the timing of coding updates for ICD-10 and for CPT, and the entities responsible for the updates.	Coding changes are implemented annually for both ICD-10-CM/PCS and CPT. The updates are implemented at different times during the year. ICD-10-CM/PCS changes are implemented on October 1, 20xx, and CPT coding updates are implemented on January 1, 20xx. CM
Discuss the process of updating a charge ticket for a hospital.	In order to prevent payer denials, a hospital should update departmental charge tickets annually (at a minimum) or as significant coding/charging changes occur. The same changes should also be coordinated with the hospital chargemaster. By proactively mak
Discuss the purpose of a healthcare compliance audit.	Multiple types of healthcare compliance audits are being conducted in the present age. To understand the purpose of a compliance audit, one must understand the different types of audits. Hospitals should be prepared in the following areas (at a minimum) w
Discuss who (the coder or the physician) is responsible for determining which documented terms match the ICD-10-PCS code descriptions.	With the implementation of ICD-10-PCS coding conventions came many new procedural terms used to construct the PCS codes. Physicians are not responsible for using the exact terminology related to the root operation. Rather, it is the coder's responsibility
Describe when a coder is required to initiate a query.	There are several reasons why a coder would initiate a physician's query. If a diagnosis and/or procedure has been determined to meet the American Hospital Association's (AHA's) ICD-10 Official Coding Guidelines for reporting but the diagnosis and /or pro
Discuss the options available for query formatting.	There are several ways to generate a query. Compliant query forms will allow for open-ended questions, multiple choice query formats, and/or limited yes/no query formats. An example of open-ended query might appear in this format: "Based upon your clinica
Briefly explain the mapping pathways.	Through the utilization of a code map, one is able to either forward map or backward map. Forward mapping is when the ICD-9 code is available and an ICD-10 code is needed, and backward mapping is the opposite— an ICD-10 code is available, but an ICD-9 cod
Discuss the role of physician champions in coding compliance.	Accurate and compliant coding is dependent upon complete and detailed documentation by the healthcare provider. The challenge for HIM professionals is convincing physicians of the importance of their role in providing valuable supportive documentation. Th
Explain how a code becomes a code.	A diagnosis and/or procedure is assigned its own code after going through a process of consideration by an advisory healthcare panel. The advisory panel, whether considering ICD-10 codes or CPT classification codes, will collaborate multiple times through
Briefly describe how, and what type of, annual coding changes occur for both ICD-10 and CPT.	Coding changes are implemented annually for both ICD-10-CM/PCS and CPT. The updates are implemented at different times during the year. ICD-10-CM/PCS changes are implemented on October 1, 20xx, and CPT coding updates are implemented on January 1, 20xx. Th
Identify required components of a query.	A physician query should include certain components in order to be a valid and/or compliant query. These components should be: Name of the contact individual submitting the query • Patient's date of service (DOS) • Patient's name • Medical Record Number
Explain the process a coder must follow when conflicting documentation exists.	Some patients admitted to an inpatient status in the hospital will be assessed by multiple physicians. Inevitably, the documentation of the various physicians will conflict. For example, the attending physician may document acute renal "failure," but the
Discuss the intent of a physician query.	A physician query is a tool of communication between CDISs/Coders and physicians to clarify incomplete, ambiguous, or conflicting documentation in the medical record. The intention of the communication tool is to facilitate completeness, accuracy, consist
Discuss the use of standardized physician query forms.	The use of standardized physician query forms by coders and /or clinical documentation improvement specialists (CDIS) is an efficient way to obtain compliant queries. Standardized queries should be created based on disease processes or circumstances that
Briefly explain general equivalence mappings and why they are important in coding updates.	General equivalence mappings (GEMs) demonstrate a network of relationships between ICD-9 codes and ICD-10 codes. It is a bidirectional map. GEMs are a translation reference tool; they may be referred to as crosswalks. There are approximately 250,000 GEMs.
Describe the elements of a chargemaster.	A hospital's chargemaster is composed of certain key elements. The typical data elements could be the following: • Charge description: Each charge has a title that describes the charge whether it is a supply, a medication, a procedure, etc. CPT/HCPCS code
Identify the types of external audits that may be requested of a hospital.	Hospitals experience audits from external agencies on a regular basis. The external auditors may be representatives of various federal agencies (e.g., Office of Inspector General, Department of Justice, Medicare Administrative Contractors). They may also
Explain who owns the medical record.	The medical record is a compilation of all written, printed, or electronic information recorded by a healthcare provider as he/she communicates with the patient during the treatment or period. Since two parties are involved in the process of creating the
Expound on the information blocking rule.	The information blocking rule allows patients to have control over who can access or use their electronic health information (EHI), with eight exceptions. The first five exceptions allow a healthcare provider to block information to a patient, whereas the
Explain the importance of passcodes in PHI security.	Passcodes or passwords are the simplest form of security for PHI. However, they can also be the easiest to crack by those with the wrong intentions. Maintaining passcodes can be frustrating for the user due to the many different passcode requirements for
Discuss how court orders/subpoenas affect the release of health information.	When a court order/subpoena is received in a health information management (HIM) department, it must be obeyed. The court order/subpoena will instruct the HIM director of which healthcare documents must be submitted. Upon receipt of the subpoena, it shoul
Briefly explain health information exchange (HIE).	Health Information Exchange (HIE) is the movement of PHI between organizations, such as hospitals and physician's offices. Through HIE processes, medical information is shared electronically, and the result is a fast communication of information that impr
Explain when it would be appropriate to destroy health information.	Health information may be destroyed when in compliance with federal and state regulations. Destruction would be applicable to inactive records only, and the following information should never be destroyed: basic information such as admission and discharge
Explain the steps involved with reporting privacy violations internally.	When an employee suspects a privacy violation, he/she should immediately alert his /her manager. If this is not an appropriate option (e.g., the manager may be the violator), the Privacy Officer and/or Corporate Compliance Officer (CCO) should be notified
Explain how the privacy and security rules are enforced.	The Office for Civil Rights (OCR) is the governmental body responsible for the enforcement of the Privacy Rule. The OCR works in conjunction with the Department of Justice (DOI) to investigate possible criminal cases of healthcare privacy breaches. The OC
Define phishing emails and provide examples.	Phishing emails are targeted emails aimed at stealing information. Healthcare entities receive phishing emails just like any other business entity. Phishing emails can appear in any of the following formats: • Emails with suspicious hyperlinks and/or atta
Define the legal health record.	The legal health record is a compilation of individually identifiable data as well as the documentation of services rendered to a patient by the healthcare provider. Each healthcare entity must define in their policies and bylaws the content of the legal
Identify the top cybersecurity concerns for health care.	Healthcare cybersecurity threats take many different forms. Some of the most obvious are: phishing emails, viruses, malware, and ransomware. All of these threats are intended to "wage war" against the attacked entity. A disgruntled healthcare employee, an
Explain the prohibition of redisclosure.	When a healthcare entity releases patient information to a third party, a statement should be included in the release that prohibits redisclosure. Once the health information is released, the releasing healthcare entity has no control over what happens to
Explain the importance of continuing education regarding healthcare privacy.	Training for providers regarding privacy is not optional for healthcare entities. HIPAA requires that all staff (including contracted individuals and volunteers) must be trained in maintaining the privacy and confidentiality of protected health informatio
Identify and describe administrative, physical, and clinical safeguards for PHI.	PHI must be protected by administrative, physical, and technical safeguards. Administrative safeguards refer to policies and procedures that address PHI security as well as a security risk assessment and risk management plans. Physical safeguards can be i
Identify the required elements of a written authorization to release information.	When a patient requests release of his/her health information to himself/herself or a third party, a written authorization is required. A written authorization to release information should include the following components: • Name of the healthcare entity
Discuss the importance of healthcare retention policies.	Healthcare retention policies must be a requirement for healthcare providers. A formal plan of retention or a record retention schedule should be developed and maintained by the HIM director. This plan should define active and inactive records/information
Briefly explain cybersecurity.	Cybersecurity is a method aimed at protecting information collected and maintained in the culture of information technology from cybercriminal activity. Cybersecurity is a plan that focuses on preventing information theft or information attacks (e.g, viru
Explain the importance of patient confidentiality.	Confidentiality is a core responsibility of a healthcare organization. This ethical practice requires healthcare workers (regardless of role) to keep all patients' health information private. The basic premise behind confidentiality is trust. Trust is nec
Describe the penalties associated with healthcare privacy violations.	The American Recovery and Reinvestment Act of 2009 established the civil penalties associated with healthcare privacy violations of HIPAA. The penalties can be as follows: Violation Minimum Penalty Maximum Penalty Unintentional disclosure of PHI $100 per
Explain "minimum necessary" in reference to PHI.	In the healthcare world of PHI, "minimum necessary" is a common phrase. Minimum necessary can be defined as: The amount of patient information that is released or accessed only when there is a legitimate need to know. When a legitimate request is validate
Discuss medical identity theft and how HIM professionals can mitigate the risk.	Medical identity theft is on the rise. The impact upon patients can be devastating because the breach may result in criminals maximizing health benefits of the victim's insurance plan, or the criminal may be successful in obtaining prescription drugs. In
Discuss confidentiality in terms of the physician-patient relationship.	The physician-patient relationship is considered to be a contractual agreement. The patient seeks out the services of a physician, and the physician accepts the patient for treatment. During this relationship, health information is gathered and exchanged
Explain the steps involved with reporting healthcare privacy violations to regulatory bodies.	Anyone can file a privacy or security violation complaint with the Office for Civil Rights (OCR). The complainant, as mentioned, can be anyone, such as a healthcare employee who works for the entity where the violation has allegedly occurred, or someone n
Explain ways to develop strong passcodes.	Passcodes are one essential way to secure PHI. They are not fail-proof, however, to hackers. Following are key tips regarding strong passcodes: Create passwords that cannot be easily guessed. • Change passwords frequently. Do not use the same password for
Explain the meaning of encryption.	Encryption is a security method or control that provides protection for confidential information. Encryption applies a mathematical algorithm that scrambles the data into a format that cannot be deciphered by people or computerized systems. The scrambled
Provide examples of ways to securely transfer emails and electronic files.	It is possible to transfer emails and electronic files containing PHI securely. There are steps involved in order to ensure the security of transmitted information. One step is to encrypt email communications. The easiest encryption method for email commu
Briefly describe the life cycle of a health record.	The life cycle of a health record is composed of four parts: creation, utilization, maintenance, and destruction. A record cannot exist without the creation of information; hence, the first phase in the life cycle. Creation of the health information happe
Briefly discuss HIPAA.	HIPAA is the acronym for Health Insurance and Portability and Accountability Act, also known as the Privacy Rule. This Act was endorsed by Congress in 2003. The Privacy Rule allows patients to have control of their own health information, all while ensuri
Discuss the importance of healthcare staff being knowledgeable of privacy and confidentiality issues.	HIPAA, also known as the Privacy Rule, is a federal law. It is important for healthcare staff to understand their role in ensuring compliance with this law. Compliance with HIPAA is not the responsibility of physicians or healthcare administrative staff o
Discuss how a provider secures health information.	Part of HIPAA addresses the Security Rule. In order for providers to comply with HIPAA's Security Rule, a risk analysis must be conducted in order to identify and implement measures to ensure the security of electronic protected health information (e-PHI)
Identify measures that could be undertaken to enforce access to only minimal necessary information.	Access to minimum necessary information means healthcare employees may only have access to PHI for which there is a legitimate need to know. Healthcare privacy departments are tasked with ensuring PHI is kept secure, and for those instances when the priva
Briefly explain the importance of a cybersecurity plan and how encryption plays a role in the plan.	While IT departments are the key individuals responsible for the security of health information, HIM professionals should be involved since they are knowledgeable of information workflows. Healthcare entities are wise to use their IT staff as well as HIM
Identify the regulatory bodies who provide guidance applicable to the retention of healthcare information.	Retention of healthcare information or medical records is regulated by various external agencies. The federal Conditions of Participation (CoPs) is one of the most prominent regulations governing this aspect of health information. The Federal Register is
Discuss the risks and benefits of information blocking.	The information blocking rule was designed to ultimately benefit patients. Patients can not only use and access their EHI almost immediately, but they can also do so on apps so their information is located in one hub instead of existing within multiple po
Define a breach of confidentiality.	A healthcare privacy breach or breach of confidentiality is an inappropriate or impermissible use or disclosure of health information. This type of breach is a direct violation of Health Insurance and Portability and Accountability Act (HIPAA), also known
Provide examples of healthcare privacy violations.	Healthcare privacy violations may come in many different forms. Some examples of violations would be: Posting protected health information (PHI) on a social media site. Inappropriate access of a patient's electronic medical record when not involved in his
Explain a patient's rights under HIPAA.	Under the HIPAA Privacy Rule, patients have rights. When patients receive healthcare services, HIPAA requires that they receive a notice of their privacy rights. This notice must describe how the healthcare entity will use/share the protected health infor
Define PHI.	Protected health information (PHI) is defined by the US Department of Health and Human Services (HHS) and is included in the Code of Federal Regulations (CFR). PHI is governed by the Health Insurance Portability and Accountability Act (HIPAA). HHS, CFR, a
Explain who is required to comply with HIPAA regulations.	Any covered entity is required to comply with the Health Insurance Portability and Accountability Act (HIPAA). How is a covered entity defined? A covered entity is defined as a healthcare provider, health plans, healthcare clearinghouses, and business ass
How many Categories is the CPT book split into?	Category I: Common medical procedures and services. Category II: Tracking codes for performance measurement. Category III: Temporary codes for new technologies.

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