RHIT - Registered Health Information Technician Medical Coding Principles Questions and Answers

Question 1

According to the UHDDS, the definition of Principal Diagnosis is the condition that:

Accepted Answer

is established after study to be chiefly responsible for the patient's admission to the hospital.

Answer

The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as 'that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.' The other options describe the primary diagnosis, a manifestation, or the admitting diagnosis, respectively.

Question 2

A patient is admitted to the hospital with acute abdominal pain. After evaluation and a CT scan, the physician diagnoses acute appendicitis and performs an appendectomy. What should be sequenced as the principal diagnosis?

Accepted Answer

Acute appendicitis.

Answer

The principal diagnosis is the condition established after study to be the reason for admission. In this case, the abdominal pain was a symptom, and after study, acute appendicitis was the definitive diagnosis that necessitated the admission and procedure. Therefore, acute appendicitis is the principal diagnosis.

Question 3

Which of the following is the primary purpose of CPT modifiers?

Accepted Answer

To provide additional information about a procedure or service without changing its definition.

Answer

CPT modifiers are two-character codes appended to a CPT code to provide additional details about the service performed, such as if it was a bilateral procedure or a reduced service, without altering the core meaning of the code itself.

Question 4

An ICD-10-CM code for a manifestation is being assigned. The coding guidelines and instructional notes in the Tabular List indicate a 'code first' note. What does this convention require the coder to do?

Accepted Answer

Sequence the underlying etiology (cause) of the disease first, followed by the manifestation code.

Answer

The 'code first' instructional note found at the manifestation code in the Tabular List requires the coder to sequence the underlying condition (etiology) before the manifestation code. The manifestation code can never be the principal diagnosis.

Question 5

A patient is admitted with dementia due to Alzheimer's disease. In ICD-10-CM, Alzheimer's disease is the etiology and dementia is the manifestation. How should these conditions be sequenced?

Accepted Answer

Code for Alzheimer's disease first, followed by the code for dementia.

Answer

According to the ICD-10-CM etiology/manifestation convention, the underlying condition (etiology) must be sequenced first, followed by the code for the manifestation. In this case, Alzheimer's disease (the etiology) is coded first, and the resulting dementia (the manifestation) is coded second.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Medical Coding Principles Questions and Answers