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

CDI programs work prospectively to ensure that physician documentation is complete, accurate, and specific enough to support precise coding and appropriate reimbursement.

Question 2

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

Accepted Answer

Retrospective audit

Answer

A retrospective audit is conducted after the patient is discharged, reviewing the coded data against the medical record documentation to identify coding errors.

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

Excludes2 means the excluded condition is not included in the code but it is acceptable to assign both codes together when the patient has both conditions simultaneously.

Question 4

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

Accepted Answer

7

Answer

Every ICD-10-PCS code is exactly 7 characters long, with each character representing a specific axis of classification such as section, body system, root operation, body part, approach, device, and qualifier.

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

When an outpatient procedure leads to a complication requiring inpatient admission, the complication is sequenced as the principal diagnosis because it is the condition chiefly responsible for the admission.

RHIA Exam Practice Test

RHIA Exam Practice Test

RHIA Clinical Classification Systems and Coding 3