RHIT DOMAIN 5 ACTUAL EXAM COMPLETE QUESTION
AND ANSWERS WITH RATIONALES 2024
The overutilization or inappropriate utilization of services and misuse of resources,
typically not a criminal or intentional act is called which of the following?
• Fraud
• Abuse
• Waste
• Audit - Answer c
Waste is the overutilization or inappropriate utilization of services and misuse of
resources, and typically is not a criminal or intentional act. Waste includes practice
like over prescribing and ordering tests inappropriately (Foltz et al. 2016, 448).
Examples of high-risk billing practices that create compliance risks for
healthcare organizations include all except which of the following?
• Altered claim forms
• Returned overpayments
• Duplicate billings
• Unbundled procedures - Answer b
Fraudulent billing practices represent a major compliance risk for healthcare
organizations. High-risk billing practices include: billing for noncovered services,
alteredclaim forms, duplicate billing, misrepresentation of facts on a claim form, failing
to returnoverpayments, unbundling, billing for medically unnecessary services,
overcoding and upcoding, billing for items or services not rendered, and false cost
reports (Bowman 2017, 440-441, 466).
Which of the following groups are included in the feedback loop between
denials, management, and clinical documentation improvement (CDI) program
staff?
• Compliance
• Office of the Inspector General
• Center for Medicare and Medicaid Services
,• Payers - Answer a
The clinical documentation improvement (CDI) manager should coordinate a feedback
loop with functional managers that involved reporting data from the department to
CDI and then from CDI back to the department. The three areas for CDI best practices
includeoperationalizing feedback loops with denials management, compliance, and
HIM (Hess 2015, 242).
Every healthcare organization's risk management plan should include the
followingcomponents except:
• Loss prevention and reduction
• Safety and security management
• Peer review
• Claims management - Answer c
Risk management programs have three functions: risk identification and analysis,
lossprevention and reduction, and claims management (Carter and Palmer 2016,
522).
A pharmacist who submits Medicaid claims for reimbursement on brand name drugs
when less expensive generic drugs were actually dispensed has committed the crime
of:
• Criminal negligence
• Fraud
• Perjury
• Products' liability - Answer b
Fraud in healthcare is defined as a deliberate false representation of fact, a failure to
disclose a fact that is material (relevant) to a healthcare transaction, damage to
another party that reasonably relies on the misrepresentation, or failure to disclose.
This situationwould fall under category 2 (Foltz et al. 2016, 448).
A provider's office calls to retrieve emergency room records for a patient's follow-
upappointment. The HIM professional refused to release the emergency room
records without a written authorization from the patient. Was this action in
compliance?
• No; the records are needed for continued care of the patient, so no
authorization isrequired
• Yes; the release of all records requires written authorization from the patient
,• No; permission of the ER physician was not obtained
• Yes; one covered entity cannot request the records from another covered
entity - Answer a
Treatment, payment, and operations (TPO) is an important concept because the
PrivacyRule provides a number of exceptions for PHI that is being used or disclosed
for TPO purposes. Treatment means providing, coordinating, or managing
healthcare or healthcare-related services by one or more healthcare providers
(Rinehart-Thompson 2016b, 223).
A notice that suspends the process or destruction of paper or electronic
records iscalled:
• Subpoena
• Consent form
• Rule
• Legal hold - Answer d
A legal hold (also known as a preservation order, preservation notice, or litigation
hold) basically suspends the processing or destruction of paper or electronic records.
It may be initiated by a court if there is concern that information may be destroyed in
cases of current or anticipated litigation, audit, or government investigation. Or, it may
be initiatedby the organization as part of their pre-litigation planning and duty to
preserve information in anticipation of litigation (Klaver 2017a, 86-87).
Which type of identity theft occurs when a patient uses another person's name
andinsurance information to receive healthcare benefits?
• Medical
• Financial
• Criminal
• Health - Answer a
Medical identity theft occurs when a patient uses another person's name and
insurance information to receive healthcare benefits. Most often this is done so a
person can receive healthcare with an insurance benefit and pay less or nothing for
the care received(Rinehart- Thompson 2016b, 247).
Which of the following situations is considered a breach of PHI?
• A nurse sees the record of a patient that she is not caring for
, • A patient's attorney is sent records not authorized by that patient
• A nurse starts to place PHI in a public area where a patient is standing and
immediatelypicks it up
• An HIM employee keys in the wrong health record number but closes it out as soon
asit is realized - Answer b
There are three exceptions to a breach. All of these answers fall into one of these
categories with the exception of the records sent to the patient's attorney. He does
not work for the covered entity and an authorization is required (Rinehart-Thompson
2016b,240).
Coding policies should include which of the following elements?
• Lunch or break schedule
• How to access the computer system
• AHIMA Standards of Ethical Coding
• Nonofficial coding guidelines - Answer c
Coding policies should include the following components: AHIMA Code of Ethics,
AHIMAStandards of Ethical Coding, Official Coding Guidelines, applicable federal and
state regulations, internal documentation policies requiring the presence of physician
documentation to support all coded diagnosis and procedure code assignments
(Schraffenberger and Kuehn 2011, 384).
A postoperative patient was prescribed Lortab prn. Nurse Jones documented in the
patient record that she administered one dose of Lortab to the patient, but never
actuallyadministered this medication. Nurse Jones then took the Lortab herself. This
action would be called?
• Drug prescribing
• Adverse drug reaction
• Sentinel event
• Drug diversion - Answer d
Drug diversion is the removal of a medication from its usual stream of preparation,
dispensing, and administration by personnel involved in those steps in order to use
orsell the medication in non-healthcare settings. An individual might take the
medicationfor personal use, to sell on the street, to sell directly to a user as a dealer
or to sell to others who will redistribute for the diverting individual (Shaw and Carter
2015, 253).
AND ANSWERS WITH RATIONALES 2024
The overutilization or inappropriate utilization of services and misuse of resources,
typically not a criminal or intentional act is called which of the following?
• Fraud
• Abuse
• Waste
• Audit - Answer c
Waste is the overutilization or inappropriate utilization of services and misuse of
resources, and typically is not a criminal or intentional act. Waste includes practice
like over prescribing and ordering tests inappropriately (Foltz et al. 2016, 448).
Examples of high-risk billing practices that create compliance risks for
healthcare organizations include all except which of the following?
• Altered claim forms
• Returned overpayments
• Duplicate billings
• Unbundled procedures - Answer b
Fraudulent billing practices represent a major compliance risk for healthcare
organizations. High-risk billing practices include: billing for noncovered services,
alteredclaim forms, duplicate billing, misrepresentation of facts on a claim form, failing
to returnoverpayments, unbundling, billing for medically unnecessary services,
overcoding and upcoding, billing for items or services not rendered, and false cost
reports (Bowman 2017, 440-441, 466).
Which of the following groups are included in the feedback loop between
denials, management, and clinical documentation improvement (CDI) program
staff?
• Compliance
• Office of the Inspector General
• Center for Medicare and Medicaid Services
,• Payers - Answer a
The clinical documentation improvement (CDI) manager should coordinate a feedback
loop with functional managers that involved reporting data from the department to
CDI and then from CDI back to the department. The three areas for CDI best practices
includeoperationalizing feedback loops with denials management, compliance, and
HIM (Hess 2015, 242).
Every healthcare organization's risk management plan should include the
followingcomponents except:
• Loss prevention and reduction
• Safety and security management
• Peer review
• Claims management - Answer c
Risk management programs have three functions: risk identification and analysis,
lossprevention and reduction, and claims management (Carter and Palmer 2016,
522).
A pharmacist who submits Medicaid claims for reimbursement on brand name drugs
when less expensive generic drugs were actually dispensed has committed the crime
of:
• Criminal negligence
• Fraud
• Perjury
• Products' liability - Answer b
Fraud in healthcare is defined as a deliberate false representation of fact, a failure to
disclose a fact that is material (relevant) to a healthcare transaction, damage to
another party that reasonably relies on the misrepresentation, or failure to disclose.
This situationwould fall under category 2 (Foltz et al. 2016, 448).
A provider's office calls to retrieve emergency room records for a patient's follow-
upappointment. The HIM professional refused to release the emergency room
records without a written authorization from the patient. Was this action in
compliance?
• No; the records are needed for continued care of the patient, so no
authorization isrequired
• Yes; the release of all records requires written authorization from the patient
,• No; permission of the ER physician was not obtained
• Yes; one covered entity cannot request the records from another covered
entity - Answer a
Treatment, payment, and operations (TPO) is an important concept because the
PrivacyRule provides a number of exceptions for PHI that is being used or disclosed
for TPO purposes. Treatment means providing, coordinating, or managing
healthcare or healthcare-related services by one or more healthcare providers
(Rinehart-Thompson 2016b, 223).
A notice that suspends the process or destruction of paper or electronic
records iscalled:
• Subpoena
• Consent form
• Rule
• Legal hold - Answer d
A legal hold (also known as a preservation order, preservation notice, or litigation
hold) basically suspends the processing or destruction of paper or electronic records.
It may be initiated by a court if there is concern that information may be destroyed in
cases of current or anticipated litigation, audit, or government investigation. Or, it may
be initiatedby the organization as part of their pre-litigation planning and duty to
preserve information in anticipation of litigation (Klaver 2017a, 86-87).
Which type of identity theft occurs when a patient uses another person's name
andinsurance information to receive healthcare benefits?
• Medical
• Financial
• Criminal
• Health - Answer a
Medical identity theft occurs when a patient uses another person's name and
insurance information to receive healthcare benefits. Most often this is done so a
person can receive healthcare with an insurance benefit and pay less or nothing for
the care received(Rinehart- Thompson 2016b, 247).
Which of the following situations is considered a breach of PHI?
• A nurse sees the record of a patient that she is not caring for
, • A patient's attorney is sent records not authorized by that patient
• A nurse starts to place PHI in a public area where a patient is standing and
immediatelypicks it up
• An HIM employee keys in the wrong health record number but closes it out as soon
asit is realized - Answer b
There are three exceptions to a breach. All of these answers fall into one of these
categories with the exception of the records sent to the patient's attorney. He does
not work for the covered entity and an authorization is required (Rinehart-Thompson
2016b,240).
Coding policies should include which of the following elements?
• Lunch or break schedule
• How to access the computer system
• AHIMA Standards of Ethical Coding
• Nonofficial coding guidelines - Answer c
Coding policies should include the following components: AHIMA Code of Ethics,
AHIMAStandards of Ethical Coding, Official Coding Guidelines, applicable federal and
state regulations, internal documentation policies requiring the presence of physician
documentation to support all coded diagnosis and procedure code assignments
(Schraffenberger and Kuehn 2011, 384).
A postoperative patient was prescribed Lortab prn. Nurse Jones documented in the
patient record that she administered one dose of Lortab to the patient, but never
actuallyadministered this medication. Nurse Jones then took the Lortab herself. This
action would be called?
• Drug prescribing
• Adverse drug reaction
• Sentinel event
• Drug diversion - Answer d
Drug diversion is the removal of a medication from its usual stream of preparation,
dispensing, and administration by personnel involved in those steps in order to use
orsell the medication in non-healthcare settings. An individual might take the
medicationfor personal use, to sell on the street, to sell directly to a user as a dealer
or to sell to others who will redistribute for the diverting individual (Shaw and Carter
2015, 253).
