FREE RHIA Questions and Answers

Question 1

Known or suspected prenatal abnormalities affecting the mother codes from category 655 should

Accepted Answer

be assigned when they affect the management of the mother

Answer

In ICD-9-CM coding, categories like 655 (Known or suspected fetal abnormality affecting management of mother) are assigned when the fetal condition directly impacts the management or care provided to the mother during pregnancy, childbirth, or the puerperium. The key criterion is that the fetal abnormality influences the clinical decisions or interventions for the mother, not merely its presence.

Question 2

Edward was diagnosed with congestive heart failure and acute pulmonary edema when he was released from the hospital. Edward's record is being coded by you, and you will code

Accepted Answer

the CHF only

Answer

When a patient is discharged with both congestive heart failure (CHF) and acute pulmonary edema, and the pulmonary edema is a direct manifestation or complication of the CHF, the CHF is coded as the principal diagnosis. Acute pulmonary edema is a common symptom of decompensated CHF, so the underlying CHF is considered the primary reason for the hospitalization. Therefore, only the CHF is coded as the principal diagnosis, with acute pulmonary edema as a secondary diagnosis.

Question 3

Special precautions must be taken to prevent the stamp from being used by a delegate when personal signature stamps are used to authenticate entries in a paper-based record. Similar controls might be used to control the usage of electronic medical records in a fully computerized patient record system.

Accepted Answer

electronic signatures

Answer

In a fully computerized patient record system, electronic signatures serve the same purpose as personal signature stamps in paper-based records: to authenticate entries. Similar to controlling the use of a physical stamp, robust controls for electronic signatures, such as unique user IDs, passwords, and audit trails, are crucial to ensure the integrity, authenticity, and non-repudiation of entries and prevent unauthorized use or delegation.

Question 4

When an exploratory laparotomy is performed then a therapeutic procedure, the coder reports this information in ICD-9-CM.

Accepted Answer

Schema mapping

Answer

When an exploratory laparotomy is performed followed by a therapeutic procedure, the coder reports this information in ICD-9-CM by assigning codes for both procedures. In the context of health information systems, 'Schema mapping' refers to the process of defining how data elements from one data model (e.g., clinical documentation of procedures) are translated and stored according to another data model (e.g., the database schema used for ICD-9-CM codes). This ensures that the coded information about both procedures is correctly captured and linked within the system.

Question 5

All lab results from one hospitalization must be rapidly compared by a health record analyst. The paper-based health record design that works well for this objective is

Accepted Answer

integrated

Answer

The integrated health record design works well for rapidly comparing all lab results from one hospitalization. In an integrated record, all forms and documents, regardless of their source (e.g., physician notes, nursing notes, lab results), are arranged in strict chronological order. This chronological flow allows a health record analyst to easily review and compare all lab results sequentially, providing a comprehensive overview of the patient's laboratory data over time.

RHIA Exam Practice Test

RHIA Exam Practice Test

FREE RHIA Questions and Answers