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

When a patient is admitted specifically because of a postprocedural complication, the complication itself is sequenced as the principal diagnosis per ICD-10-CM Official Guidelines.

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

CPT defines a new patient as one who has not received face-to-face professional services from the physician or any physician of the same specialty in the same group practice within the past three years.

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

In ICD-10-PCS, the seven-character code structure assigns Character 5 to Approach, which describes how the operative site is accessed (e.g., Open, Percutaneous, Endoscopic).

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

When the workup during an inpatient stay identifies the underlying cause of a symptom, the confirmed underlying condition (GERD) is sequenced as the principal diagnosis rather than the presenting symptom (chest pain).

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

The UHDDS establishes minimum common data elements—including the definition of principal diagnosis, other diagnoses, and procedures—that must be reported consistently for inpatient hospital discharges.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

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