RHIA Cheat Sheet 2026

The 30 highest-yield RHIA facts, distilled from real exam questions. Print it, save it as a PDF, or study it here — free, no sign-up.

1. In ICD-10-CM, the 7th character 'A' for fracture codes indicates the encounter is: → Initial encounter for active treatment of the fracture
2. What type of health record format organizes documentation by care provider discipline? → Source-oriented medical record
3. Which HIPAA-required safeguard type includes policies, training, and workforce management procedures? → Administrative safeguards
4. Under the HIPAA Privacy Rule, which of the following does NOT require patient authorization for disclosure? → Disclosure for treatment, payment, or healthcare operations (TPO)
5. The Cooperating Parties responsible for maintaining the ICD-10-CM Official Guidelines include all of the following EXCEPT: → AMA
6. What is the purpose of the National Correct Coding Initiative (NCCI)? → Prevent improper payment of procedures that should not be billed together
7. Which federal certification program evaluates whether EHR technology meets standards for meaningful use and interoperability? → ONC Health IT Certification Program
8. Which federal law imposes civil monetary penalties for knowingly submitting false claims to government healthcare programs? → The False Claims Act (FCA)
9. In EHR implementation, what does the term 'interoperability' mean? → The ability of different information systems to exchange and use health data meaningfully
10. Which prospective payment system is used to reimburse hospital outpatient services under Medicare? → Outpatient Prospective Payment System (OPPS)
11. CPT codes are organized into how many main sections (categories)? → 6
12. Which of the following is not a part of the EMTALA regulations? → Non-Medicare indigent patients must be transferred to the nearest level-1 trauma center
13. Which component of the problem-oriented medical record (POMR) lists all active diagnoses and conditions? → Problem list
14. Ambulatory Payment Classifications (APCs) are used under which Medicare payment system? → Hospital Outpatient Prospective Payment System (OPPS)
15. Under ICD-10-PCS, all procedure codes have exactly how many characters? → 7
16. Under UHDDS guidelines, which diagnosis must be identified as the principal diagnosis for inpatient coding? → The condition established after study to be chiefly responsible for admission
17. Which section of the acute care health record is legally required to be completed within 24 hours of admission? → History and physical (H&P)
18. What is the primary purpose of the master patient index (MPI) in a healthcare facility? → Uniquely identify and track each patient across encounters
19. What is a diagnosis-related group (DRG) used for in inpatient reimbursement? → Grouping inpatient cases to set a fixed Medicare payment rate
20. Which document serves as the primary source for ICD-10-CM diagnosis code assignment for inpatient records? → Discharge summary
21. HCPCS Level II codes are used primarily to report what type of services? → Supplies, equipment, and non-physician services not in CPT
22. A coding compliance audit that compares coded data against the source documentation is called a: → Retrospective audit
23. Which form is used by hospitals to submit inpatient Medicare claims? → UB-04 (CMS-1450)
24. Which code set is used to report physician and outpatient procedures for reimbursement? → CPT (Current Procedural Terminology)
25. Which leadership style involves making all decisions without seeking input from the team? → Autocratic (authoritarian) leadership
26. What is the purpose of abstracting data from health records? → Extracting specific data elements for databases, reporting, or analysis
27. There has been an alleged security breach. What idea best captures the procedure for gathering evidence? → Forensics
28. Acute care service providers are less likely than ambulatory care providers to depend on the documentation contained in the → problem list
29. What is the function of a data dictionary in a health information system? → Define the structure, format, and meaning of all data elements stored in a database
30. Which HIPAA provision requires covered entities to provide patients with a list of certain disclosures made of their PHI? → Right to an accounting of disclosures