The Joint Commission requires that medical record review is performed to evaluate adequacy, accuracy, completeness, and quality of documentation

To determine the reimbursement for a specific patient’s hospital stay, the fiscal intermediary multiplies the hospital’s established payment rate by

The HIM Director conducted productivity studies on the coders and found that 15% of their time is spent answering coding/medical necessity questions from the outpatient schedulers. The coders work an 8 hour day. How many minutes do they spend per day answering these questions?

When designing a clinical study, which sampling method is most appropriate for ensuring each participant has an equal chance of selection?

HIPAA Code Set regulations require use of three of the listed code sets,  Which code set is NOT required by HIPAA?

All of the following are output devices EXCEPT

Use of the patient record for the purposes of education, research and development, regulation, and policy making are all examples of:

A research request has been received by the Health Information Management Department from the QI Committee which plans to review charts for all patients who had a laparoscopic cholecystectomy for the month of June. Which primary search criterion is used best source to create a list of the needed records?

An internist is seeing a patient for the first time in the office. He assigns an evaluation and management code for a new patient. What documentation must be used to properly assign the evaluation and management code?

Based on documentation requirements for patient records, what document might contain this documentation? With the patient in the supine position, the abdomen was prepped and draped for the procedure. A small incision was made just below the umbilicus and the laparoscope inserted.