RHIT - Registered Health Information Technician Registered Health Information Technician Medical Coding Principles 1

Question 1

Which coding guideline applies when a patient is admitted for a complication of a surgical procedure performed during a prior hospitalization?

Accepted Answer

Code the complication as the principal diagnosis

Answer

Code the original condition that prompted the initial surgery as the principal diagnosis

Answer

Code the surgical procedure code as the principal diagnosis

Answer

Assign an external cause code as the principal diagnosis

Question 2

In CPT coding, what distinguishes a 'new patient' from an 'established patient' for E/M office visit codes?

Accepted Answer

A new patient has never visited any provider in the same specialty within the same group practice in the past 3 years

Answer

A new patient has never visited the specific physician before, regardless of group affiliation

Answer

A new patient has not been seen by the practice in the past 12 months

Answer

A new patient is one whose medical records have not yet been transferred to the practice

Question 3

Under the ICD-10-PCS structure, which axis (character) specifies the operative approach used in a procedure?

Accepted Answer

Character 5 — Approach

Answer

Character 3 — Root Operation

Answer

Character 4 — Body Part

Answer

Character 6 — Device

Question 4

A patient is admitted with chest pain. Workup reveals the chest pain is due to gastroesophageal reflux disease (GERD). Which condition should be coded as the principal diagnosis?

Accepted Answer

GERD, without esophagitis

Answer

Chest pain, unspecified

Answer

Chest pain due to GERD — both coded equally

Answer

Atypical chest pain with secondary GERD

Question 5

What is the primary purpose of the Uniform Hospital Discharge Data Set (UHDDS) in inpatient coding?

Accepted Answer

To define standardized data elements and their definitions for inpatient hospital reporting

Answer

To establish fee schedules for hospital reimbursement

Answer

To provide clinical documentation templates for physicians

Answer

To set maximum length-of-stay benchmarks by DRG

Question 6

When coding neoplasm-related encounters, which sequencing rule applies when a patient is admitted solely to receive chemotherapy for a known malignancy?

Accepted Answer

Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis and the malignancy as an additional code

Answer

Sequence the malignancy as the principal diagnosis and chemotherapy as secondary

Answer

Sequence an adverse effect code as the principal diagnosis

Answer

Sequence the neoplasm-related pain as the principal diagnosis