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CCA Exam Prep

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
Explain the four major attributes of ICD-10-PCS codes.   show
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Explain the purpose of an encounter form/superbill.   show
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show 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.  
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Discuss the structure of the ICD-10-CM alphabetic index.   show
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show 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  
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show 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  
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Identify the 6 root operations that always involve a device.   show
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Explain whether or not it is appropriate to code specificity from ancillary reports for inpatient accounts.   show
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Discuss the use of official sources of truth when assigning ICD-10 codes.   show
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Describe the HIM professional's role pertaining to data integrity.   show
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Describe how to apply coding conventions when assigning codes.   show
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Discuss the purpose of following inpatient coding guidelines. Visit mometrix.com/academy for a related video. Enter video code: 412009   show
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Explain the process of abstracting information from medical records.   show
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show 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  
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show 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  
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Explain the importance of supporting assigned codes with reliable reference sources.   show
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Identify the types of medical coding classification systems in health care.   show
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show 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  
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Describe the process of ensuring healthcare data are meaningful and useful.   show
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show 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  
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show 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  
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show 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  
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Explain the benefits of collecting accurate healthcare data.   show
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show  
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Explain the meaning of the principal diagnosis.   show
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show 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  
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Discuss what modifiers are and why they are used.   show
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show 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  
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Explain the amount and/or complexity of data reviewed in the medical decision-making risk table.   show
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show 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  
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show 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  
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show 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  
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Explain how to properly sequence ICD-10-CM codes for an inpatient.   show
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show 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  
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show 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  
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Explain the process of using the ICD-10-PCS index to locate a procedure.   show
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show 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  
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show 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  
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Discuss the purpose of following outpatient coding guidelines.   show
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Describe the four different types of examinations when assigning E/M codes.   show
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Describe the organization of the Surgery section in the CPT book.   show
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Explain the types of punctuation marks used in ICD- 10-CM coding.   show
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Explain the purpose of modifiers.   show
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show 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  
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Discuss the specific services included in a CPT surgical code.   show
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Describe the two ICD-10-CM coding abbreviations seen in the alphabetic index.   show
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Describe the documentation requirements for examinations when assigning E/M codes.   show
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Describe the services included in anesthesia CPT codes.   show
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Describe the ICD-10-PCS format.   show
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Describe the difference between modifier 52 and modifier 53.   show
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In ICD-10-PCS coding, explain how "upper" and "lower" body parts are determined.   show
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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.   show
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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   show
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show 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  
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show 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  
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show 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  
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Explain the risk of complications and/or morbidity or mortality in the medical decision-making risk table.   show
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show 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  
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show 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  
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show 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  
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Contrast the definitions of new and established patients when assigning E/M codes.   show
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show 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  
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Discuss the steps involved with assignment of a POA indicator for a combination code that identifies both the chronic condition and the acute exacerbation.   show
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show 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  
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show 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  
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show 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  
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Discuss the purpose behind instructional notes in the alphabetic index and tabular list of ICD-10-CM.   show
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show 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  
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Discuss CMS's global surgery concept.   show
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Describe the 7 characters for medical and surgical procedures.   show
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Describe the purpose of an encoder.   show
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Explain the key elements of an EHR system for a physician's practice.   show
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Identify the benefits of an electronic health record.   show
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Discuss potential problems with CAC-assigned codes and the importance of validating those codes.   show
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Discuss the meaning of "CAC."   show
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show 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  
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Briefly describe the basics of auditing code assignments.   show
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show 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.  
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Describe an electronic health record.   show
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show 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  
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show 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  
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show 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  
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Discuss the elements of a top-ranked practice management system.   show
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Explain how the workflow of CAC occurs.   show
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show 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  
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show 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  
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Identify examples of common reports used for data analytics by HIM professionals and/or healthcare data analysts.   show
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show 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  
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show 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  
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show 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  
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Explain HIE.   show
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Discuss the retention requirements for the patient index.   show
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show 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  
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Define semantic content of an EHR.   show
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show 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  
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Briefly discuss the benefits of HIE.   show
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show 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  
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show 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  
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show 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  
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Elaborate upon the management of patient identification.   show
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Briefly explain how all information should be brought together to generate an electronic record.   show
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Identify types of data analysis tools.   show
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show 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  
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Explain the purpose of the ONC for Health Information Technology.   show
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show 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  
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Outline the components of a medical record.   show
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show 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  
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Discuss the three key forms of HIE.   show
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show 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  
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show 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  
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show 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  
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show 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  
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Discuss the IGPHC.   show
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Discuss the components of a quantitative analysis.   show
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Discuss ways to retrieve medical information from an archived state.   show
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show 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  
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show 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  
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Explain how to locate an NCD/LCD online.   show
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Describe the two forms used for submitting claims.   show
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Identify the most common types of claim denials.   show
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Explain how proper training and up-to-date resources can prevent denials.   show
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Discuss how risk adjustment coding affects the revenue cycle, and define risk adjustment factors.   show
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show 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,  
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show 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  
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show 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  
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Discuss the purpose of identifying HACs.   show
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Discuss ways to generate clean claims, thus reducing the number of denials.   show
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show 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  
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show 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  
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Discuss the types of financial reports that are relevant to both coding and patient financial services.   show
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Briefly explain the life cycle of a claim.   show
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show 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  
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show 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  
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Identify and explain the Medicare code edits for ICD- 10-PCS codes.   show
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Discuss the meaning of medical necessity.   show
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Discuss the consequences of filing a claim with falsified information.   show
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show 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  
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show 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  
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show 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  
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Identify ways to promote clinical documentation improvement opportunities with physicians.   show
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Explain the purpose of linking diagnoses and CPT codes.   show
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show 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  
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show 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  
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show 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  
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show 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  
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Explain the process of adjudication.   show
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show 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  
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Discuss how to determine if two or more CPT codes should be bundled.   show
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show 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  
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show 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  
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show 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  
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Explain whether or not ICD-10-CM codes affect APC payments.   show
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show 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  
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Explain how packaging of items and services affects APC payments.   show
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show 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  
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Discuss DRG weights and their impact upon reimbursement.   show
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Define HCC.   show
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show 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,  
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Explain the types of payment models for which the coding and financial services' departments must be familiar.   show
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show 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  
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show 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  
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Describe how to locate APC payment tables on CMS.gov.   show
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show 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  
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show 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,  
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Briefly describe governmental audits.   show
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Explain the purpose of a Chargemaster.   show
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Briefly discuss the implementation of ICD-10 coding changes that occurred on October 1, 2015.   show
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Provide examples of a leading query.   show
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show 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  
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Explain the meaning of coding compliance.   show
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show 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  
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show 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  
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show 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  
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show 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  
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Discuss AHIMA's Standards of Ethical Coding.   show
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show 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  
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Identify physician documentation vulnerabilities.   show
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show 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  
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Define the types of standards to establish to ensure ethical coding.   show
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show 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  
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show 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  
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Discuss the process of updating a charge ticket for a hospital.   show
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Discuss the purpose of a healthcare compliance audit.   show
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Discuss who (the coder or the physician) is responsible for determining which documented terms match the ICD-10-PCS code descriptions.   show
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show 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  
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show 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  
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Briefly explain the mapping pathways.   show
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Discuss the role of physician champions in coding compliance.   show
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Explain how a code becomes a code.   show
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show 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  
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show 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  
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show 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  
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show 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  
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show 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  
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Briefly explain general equivalence mappings and why they are important in coding updates.   show
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Describe the elements of a chargemaster.   show
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show 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  
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Explain who owns the medical record.   show
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Expound on the information blocking rule.   show
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show 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  
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Discuss how court orders/subpoenas affect the release of health information.   show
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Briefly explain health information exchange (HIE).   show
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show 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  
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Explain the steps involved with reporting privacy violations internally.   show
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show 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  
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show 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  
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show 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  
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show 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  
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Explain the prohibition of redisclosure.   show
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Explain the importance of continuing education regarding healthcare privacy.   show
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show 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  
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Identify the required elements of a written authorization to release information.   show
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show 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  
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show 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  
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show 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  
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Describe the penalties associated with healthcare privacy violations.   show
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Explain "minimum necessary" in reference to PHI.   show
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Discuss medical identity theft and how HIM professionals can mitigate the risk.   show
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Discuss confidentiality in terms of the physician-patient relationship.   show
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Explain the steps involved with reporting healthcare privacy violations to regulatory bodies.   show
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show 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  
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Explain the meaning of encryption.   show
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show 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  
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Briefly describe the life cycle of a health record.   show
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Briefly discuss HIPAA.   show
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show 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  
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Discuss how a provider secures health information.   show
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show 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  
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show 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  
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show 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  
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show 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  
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Define a breach of confidentiality.   show
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show 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  
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show 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  
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show 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  
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show 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  
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How many Categories is the CPT book split into?   show
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