RHIA Clinical Classification Systems and Coding 3

Question 1

Clinical Documentation Improvement (CDI) programs primarily aim to achieve which goal?

Accepted Answer

Ensure physician documentation accurately reflects the patient's clinical condition for coding

Answer

Reduce the number of physician queries submitted

Answer

Eliminate the need for health information management coders

Answer

Increase the length of hospital stays

Question 2

A coding compliance audit that compares coded data against the source documentation is called a:

Accepted Answer

Retrospective audit

Answer

Prospective audit

Answer

Concurrent audit

Answer

Validation audit

Question 3

Which of the following correctly describes the 'Excludes2' note in ICD-10-CM?

Accepted Answer

The excluded condition is not included here but may be reported together if both conditions exist

Answer

The excluded code can never be used with the code above it

Answer

It replaces the 'Excludes1' note in all circumstances

Answer

It indicates the code is invalid for reporting

Question 4

Under ICD-10-PCS, all procedure codes have exactly how many characters?

Accepted Answer

7

Answer

5

Answer

6

Answer

8

Question 5

When a patient is admitted as an inpatient following an outpatient procedure that results in a complication, which diagnosis is sequenced as principal?

Accepted Answer

The complication that caused the inpatient admission

Answer

The original reason for the outpatient procedure

Answer

The patient's most chronic condition

Answer

The condition with the highest DRG weight

Question 6

The Cooperating Parties responsible for maintaining the ICD-10-CM Official Guidelines include all of the following EXCEPT:

Accepted Answer

AMA

Answer

AHIMA

Answer

AHA

Answer

CMS

Question 7

In ICD-10-CM, the 7th character 'A' for fracture codes indicates the encounter is:

Accepted Answer

Initial encounter for active treatment of the fracture

Answer

Subsequent encounter for fracture with routine healing

Answer

Sequela of the fracture

Answer

An encounter for an open fracture only