RHIT (Registered Health Information Technician) Exam — Questions and Answers

Question 1: What is the difference between 'excision' and 'resection' in ICD-10-PCS?

Excision requires anesthesia and resection does not
Excision removes a PORTION while resection removes ALL of a body part without replacement (Correct answer)
They are the same
Excision is for tumors and resection for organs

Correct answer: Excision removes a PORTION while resection removes ALL of a body part without replacement

Excision (root operation B) removes a portion; resection (root operation T) removes the entire body part.

Question 2: Which of the following entries in a health record would be considered an unauthorized alteration?

Addendum added by the treating physician with current date and time
Correction with a single line through the error, dated and initialed
Deletion of a prior erroneous entry with no notation (Correct answer)
Late entry labeled as such with date, time, and provider signature

Correct answer: Deletion of a prior erroneous entry with no notation

Deleting an entry without notation constitutes falsification of the health record; errors must be corrected through approved amendment procedures.

Question 3: A HIM department notices that the average discharge record completion time increased from 14 days to 22 days over six months. The FIRST step in a formal performance improvement process would be to:

Benchmark against national standards
Implement corrective action immediately
Report the issue to administration
Define and measure the problem clearly (Correct answer)

Correct answer: Define and measure the problem clearly

In the PDCA or DMAIC framework, the first step is to define and measure the problem before analyzing root causes or implementing solutions.

Question 4: Which of the following is a required implementation specification under the HIPAA Security Rule's administrative safeguards?

Facility access controls
Workstation security
Encryption and decryption
Security management process (Correct answer)

Correct answer: Security management process

Security management process is a required administrative safeguard that includes conducting risk analyses and implementing risk management procedures.

Question 5: In a health data quality review, a 'false positive' result from a validation rule would mean:

A truly erroneous record was correctly flagged
A duplicate record was successfully merged
A missing value was automatically populated
A valid record was incorrectly flagged as an error (Correct answer)

Correct answer: A valid record was incorrectly flagged as an error

A false positive occurs when a validation rule flags a record as problematic even though the data is actually correct.

Question 6: Which of the following best describes the concept of 'data granularity' in health information management?

The level of detail at which data is recorded (Correct answer)
The total volume of data stored in an EHR system
The number of data entry errors per 1,000 records
The frequency with which data is backed up

Correct answer: The level of detail at which data is recorded

Data granularity refers to the level of detail captured in a data element. For example, recording a patient's weight to the nearest tenth of a kilogram is more granular than recording it to the nearest kilogram, affecting precision and clinical utility.

Question 7: Under the HITECH Act, which entities became directly liable for HIPAA compliance?

Business associates as well as covered entities (Correct answer)
Federal healthcare agencies
Only covered entities with more than 50 employees
Health plans only

Correct answer: Business associates as well as covered entities

The HITECH Act extended direct HIPAA liability to business associates, meaning they are subject to HIPAA Security Rule requirements and civil and criminal penalties.

Question 8: What is a key difference between the designated record set (DRS) and the legal health record?

The DRS is broader and includes records used to make decisions about an individual; the legal health record is the organization's defined official record (Correct answer)
The DRS is used only for billing purposes
The legal health record includes all metadata and audit logs; the DRS does not
There is no difference; the terms are interchangeable under HIPAA

Correct answer: The DRS is broader and includes records used to make decisions about an individual; the legal health record is the organization's defined official record

The DRS, defined by HIPAA, is a broader set of records used in decision-making, while the legal health record is the facility-defined official business record.

Question 9: A 200-bed hospital recorded 1,460 inpatient service days in a week. What is the daily bed occupancy rate?

91%
85%
65%
73% (Correct answer)

Correct answer: 73%

Daily occupancy rate = inpatient service days / (beds × days in period) × 100 = 1,460 / (200 × 7) × 100 = 1,460 / 1,400 × 100 ≈ 73% (rounded to available capacity context: 1,460/2,000 = 73%).

Question 10: In a frequency distribution, what does a bimodal distribution indicate?

The data has two distinct peaks or clusters (Correct answer)
The data contains no outliers
The mean and median are equal
The data is perfectly symmetrical around the mean

Correct answer: The data has two distinct peaks or clusters

A bimodal distribution has two distinct peaks, suggesting the data may come from two different subpopulations.

Question 11: What is the purpose of a contingency plan in health information management?

To establish procedures for responding to emergencies and ensuring continued access to critical data during disruptions (Correct answer)
To plan hospital expansion
To manage vendor contracts
To determine employee compensation

Correct answer: To establish procedures for responding to emergencies and ensuring continued access to critical data during disruptions

A contingency plan establishes procedures for responding to emergencies like system failures or natural disasters.

Question 12: In the context of the Stark Law (Physician Self-Referral Law), which of the following is TRUE?

It applies only to criminal referral arrangements
It only applies to Medicaid referrals
It requires intent to defraud to establish a violation
It prohibits physician referrals for designated health services to entities in which the physician has a financial relationship, with limited exceptions (Correct answer)

Correct answer: It prohibits physician referrals for designated health services to entities in which the physician has a financial relationship, with limited exceptions

The Stark Law is a strict-liability civil statute prohibiting referrals for designated health services to financially related entities, with no intent requirement.

Question 13: A quality team uses a Pareto chart to analyze claim denial reasons. What does this chart identify?

The vital few causes that account for the majority of denials, following the 80/20 principle (Correct answer)
Geographic distribution of denials
Chronological order of denials
Average dollar amount of denials

Correct answer: The vital few causes that account for the majority of denials, following the 80/20 principle

A Pareto chart displays causes in descending frequency, identifying the vital few that account for most problems.

Question 14: What special protections does HIPAA provide for psychotherapy notes?

Only the patient can access them
Not covered by HIPAA
Same protections as all other PHI
Separate patient authorization required for most uses and disclosures, beyond standard TPO permissions (Correct answer)

Correct answer: Separate patient authorization required for most uses and disclosures, beyond standard TPO permissions

Psychotherapy notes require specific authorization for nearly all uses and are excluded from standard TPO permissions.

Question 15: Which condition would most likely trigger a CDI query for malnutrition?

Albumin of 2.1 g/dL and physician documents only 'poor appetite' (Correct answer)
Patient ate a full meal on day 2 of admission
Patient BMI of 22 with no dietary concerns
Patient requested a vegetarian meal tray

Correct answer: Albumin of 2.1 g/dL and physician documents only 'poor appetite'

A low albumin combined with incomplete documentation suggests malnutrition may be present but underdocumented, warranting a physician query.

Question 16: In a frequency distribution of patient ages, the most frequently occurring age is 45. What statistical term describes this?

Mode (Correct answer)
Median
Mean
Standard deviation

Correct answer: Mode

The mode is the value that occurs most frequently in a data set.

Question 17: What does the term 'interoperability' mean in the context of health information technology?

The capacity of a single system to perform multiple functions
The practice of sharing login credentials
The ability of staff to work across departments
The ability of different health information systems to exchange, interpret, and use data effectively (Correct answer)

Correct answer: The ability of different health information systems to exchange, interpret, and use data effectively

Interoperability is the ability of different health information systems to communicate, exchange data, and use the exchanged information meaningfully.

Question 18: What is the primary purpose of the Uniform Hospital Discharge Data Set (UHDDS) in inpatient coding?

To establish fee schedules for hospital reimbursement
To provide clinical documentation templates for physicians
To set maximum length-of-stay benchmarks by DRG
To define standardized data elements and their definitions for inpatient hospital reporting (Correct answer)

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

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.

Question 19: A facility discovers that an employee accessed the electronic health records of a celebrity patient out of curiosity, without a treatment relationship. Under HIPAA, this is classified as:

An impermissible use resulting in a presumed breach, unless a low probability of compromise analysis clears it (Correct answer)
An authorized incidental disclosure
An excepted treatment disclosure
A permissible workforce training activity

Correct answer: An impermissible use resulting in a presumed breach, unless a low probability of compromise analysis clears it

Unauthorized snooping by a workforce member is an impermissible use that is presumed to be a breach unless a four-factor risk assessment demonstrates low probability of compromise.

Question 20: Which of the following is an example of a duplicate MPI entry?

A patient with both an inpatient and outpatient record
A patient seen at two different facilities in the same health system
Two patients with the same name but different dates of birth
The same patient registered twice under slightly different name spellings (Correct answer)

Correct answer: The same patient registered twice under slightly different name spellings

A duplicate MPI entry occurs when the same individual has been registered more than once, creating multiple records for a single patient.

Question 21: Which disclosure is mandated by law and does NOT require patient authorization?

Disclosure to another health system for treatment coordination
Disclosure to a patient's employer for workers' compensation claims in states with applicable law (Correct answer)
Disclosure to a marketing agency for promotional use
Disclosure to a patient's attorney upon request

Correct answer: Disclosure to a patient's employer for workers' compensation claims in states with applicable law

Many states have workers' compensation laws that require disclosure of relevant health information without patient authorization when the employer or insurer is a party to the claim.

Question 22: What is the 'minimum necessary' standard under HIPAA?

Covered entities must disclose the minimum amount of PHI needed to accomplish the intended purpose (Correct answer)
Records must be redacted to one page before release
Covered entities must always share complete records with requesting parties
Patients may only request a minimum of five pages of records

Correct answer: Covered entities must disclose the minimum amount of PHI needed to accomplish the intended purpose

The minimum necessary standard requires covered entities to make reasonable efforts to limit PHI disclosure to the minimum needed for the intended purpose.

Question 23: In the month of June, a 150-bed hospital had a total of 3,600 inpatient service days. The hospital discharged 450 patients during the same period. What was the average length of stay (ALOS) for June?

8.0 days (Correct answer)
0.125 days
3.3 days
24.0 days

Correct answer: 8.0 days

The average length of stay (ALOS) is calculated by dividing the total inpatient service days (also known as discharge days) by the total number of discharges during a specific period. In this case, 3,600 days / 450 discharges = 8.0 days.

Question 24: System downtime procedures in a hospital HIM department are designed to:

Allow manual, paper-based workflows until the system is restored (Correct answer)
Permanently replace the electronic system
Archive all electronic records to external storage
Restrict all patient care until systems are online

Correct answer: Allow manual, paper-based workflows until the system is restored

Downtime procedures establish manual backup processes so clinical and administrative operations can continue during system outages.

Question 25: Which present-on-admission (POA) indicator is assigned when the condition is present at the time of inpatient admission?

Y (Correct answer)
W
N
U

Correct answer: Y

POA indicator 'Y' (Yes) is assigned when the condition was present at the time of the inpatient admission.

Question 26: Following a failed suicide attempt, a patient spent 60 days in the psychiatric ward. The psychotherapy notes from the psychiatrist have been requested by the insurance provider. The proper response is to, right?

ask the psychiatrist for permission to send the notes.
send a copy of the notes.
refer the request to the ethics committee.
decline to send a copy of the notes. (Correct answer)

Correct answer: decline to send a copy of the notes.

The appropriate reaction is to reject to send a copy of the psychiatrist's psychotherapy records if a patient was hospitalized in the psychiatric unit for 60 days after making an unsuccessful suicide attempt. According to HIPAA, psychotherapy notes are not regarded as a component of the EHR and do not include information required for claims. Court orders and patient consent are also required for the release of psychotherapy notes.

Question 27: A coder assigns ICD-10-CM code Z87.11 (personal history of peptic ulcer disease) to a patient with an active peptic ulcer. Is this correct?

Yes, history codes should always be assigned
Yes, because all past conditions should be coded
No, because peptic ulcers cannot be coded
No, history codes should only be used when the condition no longer exists (Correct answer)

Correct answer: No, history codes should only be used when the condition no longer exists

History codes should only be assigned when a condition no longer exists and the patient is not receiving treatment for it.

Question 28: What is the purpose of the OIG Work Plan in healthcare compliance?

To define patient treatment protocols
To manage employee schedules
To outline the government's planned areas of focus for audits and enforcement in healthcare (Correct answer)
To schedule building maintenance

Correct answer: To outline the government's planned areas of focus for audits and enforcement in healthcare

The OIG Work Plan identifies areas of focus for audit and investigation activities.

Question 29: A data integrity audit reveals that a patient's blood type is recorded as Type A in the lab system but Type O in the EHR. What type of issue is this?

An accessibility issue
A granularity issue
A timeliness issue
A consistency issue (Correct answer)

Correct answer: A consistency issue

When the same data element has different values across systems, it represents a consistency issue.

Question 30: Which type of study design is considered the strongest evidence for establishing a causal relationship?

Cross-sectional study
Case-control study
Retrospective cohort study
Randomized controlled trial (Correct answer)

Correct answer: Randomized controlled trial

Randomized controlled trials (RCTs) minimize bias through random assignment and are the gold standard for establishing causality.

Question 31: Under the Medicare Conditions of Participation for medical records, which timeframe is required for completion of a medical record after patient discharge?

60 days
7 days
30 days (Correct answer)
24 hours

Correct answer: 30 days

CMS Conditions of Participation at 42 CFR §482.24 require that medical records be completed within 30 days following patient discharge.

Question 32: What is the primary purpose of the False Claims Act (FCA) in healthcare?

To regulate pharmaceutical pricing
To establish hospital building codes
To manage healthcare worker licensing
To prevent and penalize the submission of false or fraudulent claims to government programs (Correct answer)

Correct answer: To prevent and penalize the submission of false or fraudulent claims to government programs

The False Claims Act prohibits knowingly submitting false claims to the government for payment.

Question 33: A hospital has 300 staffed beds and recorded 90,000 inpatient service days in a 365-day year. What is the bed occupancy rate?

90.4%
72.5%
82.2% (Correct answer)
68.1%

Correct answer: 82.2%

Bed occupancy rate = (90,000 ÷ (300 × 365)) × 100 = (90,000 ÷ 109,500) × 100 ≈ 82.2%.

Question 34: A record overlay in an EHR is most dangerous because it:

Creates extra storage costs
Causes a billing code to be unassigned
Results in one patient's health information appearing in another patient's record (Correct answer)
Delays discharge summary completion

Correct answer: Results in one patient's health information appearing in another patient's record

An overlay merges records incorrectly so that one patient's data populates another patient's chart, creating serious patient safety risks.

Question 35: Antineoplastic immunotherapy (Z51.12) is being used to treat a patient's multiple myeloma (C90.00), which has not yet entered remission. Additionally, the patient has a history of medication-controlled supraventricular tachycardia (I46.1). How would you order these diagnoses from first to last?

C90.00, Z51.12, and I46.1
I46.1, Z51.12, C90.00
Z51.12, C90.00, and I46.1 (Correct answer)
I46.1, C90.00, and Z51.12

Correct answer: Z51.12, C90.00, and I46.1

The main diagnosis (Z51.2) for a patient receiving immunotherapy (or chemotherapy, or radiation treatment) specifically for a malignancy is stated after the disease to which the therapy is applied, multiple myeloma (C90.00). The list of further chronic illnesses continues with SVT (I46.1). The codes are Z51.12, C90.00, and I46.1 in that order.

Question 36: A health information technician discovers that two different medical record numbers have been assigned to the same patient. What is this error called?

Duplicate (Correct answer)
Overlay
Merge error
Overlap

Correct answer: Duplicate

When the same patient is assigned two or more medical record numbers, it is called a duplicate.

Question 37: Which HIPAA provision allows patients to request corrections to their medical records?

Right to amend (Correct answer)
Right to access
Right to accounting of disclosures
Right to request restrictions

Correct answer: Right to amend

The right to amend allows patients to request corrections to inaccurate or incomplete PHI in a covered entity's designated record set.

Question 38: In Six Sigma, what does the term 'DMAIC' stand for?

Define, Measure, Analyze, Improve, Control (Correct answer)
Define, Monitor, Analyze, Implement, Check
Document, Monitor, Assess, Implement, Confirm
Design, Manage, Analyze, Integrate, Complete

Correct answer: Define, Measure, Analyze, Improve, Control

DMAIC stands for Define, Measure, Analyze, Improve, and Control — the structured problem-solving framework used in Six Sigma to improve existing processes.

Question 39: Under HIPAA, which of the following is considered a 'covered entity'?

An IT consultant hired by a clinic
A health plan that pays for medical care (Correct answer)
A medical software vendor
A janitorial company servicing a hospital

Correct answer: A health plan that pays for medical care

Health plans, healthcare clearinghouses, and healthcare providers who transmit health information electronically are the three categories of covered entities under HIPAA.

Question 40: Which of the following is the BEST example of secondary use of health record data?

A physician reviewing a patient's allergy list before prescribing
A nurse documenting vital signs during a patient's visit
A researcher using de-identified patient data to study disease trends (Correct answer)
A pharmacist verifying a medication order

Correct answer: A researcher using de-identified patient data to study disease trends

Secondary use refers to using health data for purposes other than direct patient care, such as research, quality improvement, or public health reporting.

Question 41: Which data visualization type is BEST suited for showing the relationship between two continuous variables?

Scatter plot (Correct answer)
Histogram
Bar chart
Pie chart

Correct answer: Scatter plot

A scatter plot displays the relationship between two continuous variables, with each point representing a pair of values.

Question 42: A hospital's case mix index (CMI) has been declining over the past quarter. Which department should be consulted first?

Facilities management
Marketing
Clinical documentation improvement (CDI) (Correct answer)
Human resources

Correct answer: Clinical documentation improvement (CDI)

A declining CMI often indicates documentation gaps that result in lower-weighted DRG assignments.

Question 43: What is the purpose of a job description?

To define duties, responsibilities, qualifications, reporting relationships, and performance standards (Correct answer)
To determine strategic goals
To track vacation time
To assign office space

Correct answer: To define duties, responsibilities, qualifications, reporting relationships, and performance standards

A job description formally documents the essential functions, requirements, and standards for a position.

Question 44: A hospital's average daily census is calculated by dividing the total inpatient service days by:

The number of staffed beds available
The number of admissions during the period
The number of discharges during the period
The number of calendar days in the period (Correct answer)

Correct answer: The number of calendar days in the period

Average daily census equals total inpatient service days divided by the number of calendar days in the reporting period.

Question 45: What are key components of an effective employee orientation program in HIM?

Only providing the employee handbook
Showing the employee their desk
Assigning a full workload immediately
Comprehensive introduction to policies, procedures, job-specific training, compliance requirements, and technology systems (Correct answer)

Correct answer: Comprehensive introduction to policies, procedures, job-specific training, compliance requirements, and technology systems

Effective orientation includes organizational overview, compliance training, department orientation, and job-specific training.

Question 46: Which CPT code range covers Evaluation and Management (E/M) services for hospital inpatient initial care?

99201–99215
99221–99223 (Correct answer)
99231–99233
99241–99245

Correct answer: 99221–99223

CPT codes 99221–99223 are used for initial hospital inpatient care, with varying levels of complexity.

Question 47: Which network topology connects all nodes directly to a central hub or switch, making it easy to add devices but creating a single point of failure?

Bus topology
Ring topology
Mesh topology
Star topology (Correct answer)

Correct answer: Star topology

In a star topology, all devices connect to a central hub or switch; if the hub fails, all connected nodes lose connectivity.

Question 48: A patient's records are requested via subpoena. The HIM professional should FIRST:

Obtain a written patient authorization before proceeding
Consult with the facility's legal counsel before releasing any information (Correct answer)
Release the records immediately to comply with the court order
Notify the patient's insurance company of the subpoena

Correct answer: Consult with the facility's legal counsel before releasing any information

The HIM professional should consult legal counsel first, as a subpoena alone may not override state privacy protections without a court order.

Question 49: What is the primary purpose of the Master Patient Index (MPI) in a healthcare facility?

To uniquely identify each patient across all encounters (Correct answer)
To store physician credentials
To track employee schedules
To manage financial transactions

Correct answer: To uniquely identify each patient across all encounters

The MPI serves as the central database that uniquely identifies each patient and links all their records across the healthcare system.

Question 50: A primary care clinic needs to send a patient's summary of care record to a specialist at a different facility that uses a separate EHR system. To ensure the receiving system can process and interpret the data correctly, which standard is most commonly used for structuring this clinical document exchange?

DICOM
Consolidated-Clinical Document Architecture (C-CDA) (Correct answer)
ANSI X12
NCPDP Script

Correct answer: Consolidated-Clinical Document Architecture (C-CDA)

The Consolidated-Clinical Document Architecture (C-CDA) is an HL7 standard that provides a library of templates for clinical documents like summary of care records. It is the required standard under federal programs for creating and exchanging such documents to ensure interoperability between different certified EHR systems.

Question 51: A covered entity discovers a potential breach. The HIPAA breach notification rule presumes that an impermissible use or disclosure is a breach unless:

The covered entity reports it to HHS within 24 hours
The patient was notified within 10 days
The data was encrypted at rest
A low probability assessment shows the PHI was not compromised (Correct answer)

Correct answer: A low probability assessment shows the PHI was not compromised

The covered entity can rebut the presumption of breach by demonstrating through a four-factor risk assessment that there is a low probability the PHI was compromised.

Question 52: The Genetic Information Nondiscrimination Act (GINA) Title II prohibits employers from using genetic information in employment decisions. In the context of HIPAA, genetic information is classified as:

Freely disclosable with patient authorization
Protected only if it relates to a current diagnosis
Excluded from PHI protections
A type of PHI that is generally prohibited from use for underwriting purposes by health plans (Correct answer)

Correct answer: A type of PHI that is generally prohibited from use for underwriting purposes by health plans

HIPAA, as amended by GINA, prohibits health plans from using genetic information for underwriting and treats it as a type of PHI.

Question 53: A hospital had 50 patient deaths within a 30-day period. Of those, 5 were coroner's cases that were not brought back to the hospital for autopsy. The hospital pathology department performed autopsies on 18 of the remaining deaths. Which calculation represents the hospital's net autopsy rate?

(18 / 45) * 100 (Correct answer)
(5 / 50) * 100
(18 / 50) * 100
(18 / 55) * 100

Correct answer: (18 / 45) * 100

The net autopsy rate refines the gross rate by excluding deaths of patients whose bodies were not available for autopsy (e.g., coroner's cases). The denominator is the total number of inpatient deaths minus the unautopsied coroner's cases. The calculation is (18 autopsies / (50 total deaths - 5 coroner's cases)) * 100.

Question 54: A patient requests access to their medical records. Under HIPAA, the covered entity must provide access within how many days?

90 days
30 days (Correct answer)
15 days
60 days

Correct answer: 30 days

HIPAA requires covered entities to provide access to requested records within 30 days, with one 30-day extension allowed if the entity notifies the patient.

Question 55: 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?

Code for dementia first, followed by the code for Alzheimer's disease.
Report only the code for dementia as it was the reason for admission.
Assign a combination code that includes both conditions.
Code for Alzheimer's disease first, followed by the code for dementia. (Correct answer)

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

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.

Question 56: According to the principle of span of control, which HIM department configuration would typically require an additional supervisory level?

One director managing 30 direct reports (Correct answer)
One lead coder supervising 6 staff
One supervisor managing 5 coders
One manager overseeing 3 team leads

Correct answer: One director managing 30 direct reports

Span of control refers to the number of employees a manager can effectively supervise; managing 30 direct reports typically exceeds an effective span and warrants an additional supervisory tier.

Question 57: The Medicare Outpatient Code Editor (OCE) carries out the coding, coverage, clinical, and adjustments listed below.

cause
coverage
claims. (Correct answer)
cancellation.

Correct answer: claims.

The following types of modifications are carried out by the Medicare Outpatient Code Editor (OCE): Coding: Verifies that the claim does not involve just inpatient operations, that the codes are correct, and that there are no disputes based on age or gender. Guarantees that claims are for procedures that are covered. Clinical: Assures the accuracy of the demographic data. Claims: Assures accuracy of dates, units of service, and observations.

Question 58: In performance improvement, what does a 'tracer methodology' involve?

Mapping data flows through health information systems
Following a patient's care experience across departments to evaluate systems (Correct answer)
Tracking financial transactions through the revenue cycle
Auditing coding accuracy across the facility

Correct answer: Following a patient's care experience across departments to evaluate systems

The Joint Commission's tracer methodology evaluates the care, treatment, and services delivered to individual patients by tracing their experience through the organization's processes and systems.

Question 59: A fishbone (Ishikawa) diagram is primarily used to:

Display frequency distributions
Compare data from two variables
Identify possible causes of a problem (Correct answer)
Track performance trends over time

Correct answer: Identify possible causes of a problem

A fishbone diagram visually maps potential root causes of a problem across categories such as people, process, equipment, and environment.

Question 60: What is the role of a data dictionary in health information systems?

To define each data element including its name, definition, format, allowable values, and source (Correct answer)
To store patient demographic information
To encrypt data for security purposes
To translate medical terminology into layman's terms

Correct answer: To define each data element including its name, definition, format, allowable values, and source

A data dictionary provides standardized definitions for all data elements in an information system.

Question 61: A hospital's case mix index (CMI) increased from 1.45 to 1.62. What does this indicate?

The hospital is treating more complex or resource-intensive patients on average (Correct answer)
The hospital treated fewer patients
The hospital's readmission rate increased
The denial rate has decreased

Correct answer: The hospital is treating more complex or resource-intensive patients on average

A higher CMI reflects a greater proportion of complex, resource-intensive cases, which generally correlates with higher Medicare reimbursement per case.

Question 62: What is 'data provenance' in health informatics?

The documented history of data's origin, movement, and transformation (Correct answer)
The geographic origin of data collected in clinical trials
A method for encrypting patient data at rest
The process of removing duplicate patient records

Correct answer: The documented history of data's origin, movement, and transformation

Data provenance tracks where data came from, how it was transformed, and who handled it, which is essential for trust and integrity.

Question 63: Which of the following individuals has the right to authorize release of a deceased patient's records?

No one; deceased records can never be released
Any family member of the deceased
The deceased patient's personal representative or estate executor (Correct answer)
The attending physician at time of death

Correct answer: The deceased patient's personal representative or estate executor

After a patient's death, the personal representative (such as an estate executor) holds the rights to authorize disclosure of the deceased patient's PHI.

Question 64: In the absence of a more stringent state law, the CMS Conditions of Participation require hospitals to retain medical records for a minimum of how many years?

3 years
7 years
10 years
5 years (Correct answer)

Correct answer: 5 years

The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation for Hospitals (42 CFR §482.24) mandate that medical records must be retained in their original or a legally reproduced form for at least 5 years. State laws may require a longer period, in which case the stricter rule must be followed.

Question 65: Under HIPAA, which of the following is NOT considered protected health information (PHI)?

Patient's date of birth linked to a diagnosis
Patient's medical record number
De-identified data with all 18 identifiers removed (Correct answer)
Patient's geographic region smaller than a state

Correct answer: De-identified data with all 18 identifiers removed

Data from which all 18 HIPAA-specified identifiers have been removed meets the de-identification standard and is not considered PHI.

Question 66: What is a HIPAA Security Rule 'addressable' implementation specification?

A specification where the organization must assess if it is reasonable, and if not, document why and implement an alternative (Correct answer)
A specification that is optional
Only addresses physical security
Only applies to large hospitals

Correct answer: A specification where the organization must assess if it is reasonable, and if not, document why and implement an alternative

Addressable does not mean optional; it requires assessment, documentation, and either implementation or an equivalent alternative.

Question 67: Which data quality characteristic ensures that a data element has a value whenever it is required and is not left blank?

Completeness (Correct answer)
Accuracy
Consistency
Timeliness

Correct answer: Completeness

Completeness ensures that all required data fields contain values and that no required information is missing.

Question 68: What is the primary goal of a Clinical Documentation Improvement (CDI) program?

Reduce the number of patient admissions
Increase the number of coded diagnoses per encounter
Eliminate all paper records from the health system
Ensure physician documentation accurately reflects the severity of illness and quality of care (Correct answer)

Correct answer: Ensure physician documentation accurately reflects the severity of illness and quality of care

CDI programs ensure that physician documentation accurately and completely reflects the patient's clinical status to support accurate coding, reimbursement, and quality reporting.

Question 69: What is the difference between computer-assisted coding (CAC) and autonomous coding?

CAC is used only for inpatient coding
There is no difference
Autonomous coding is less accurate than manual coding
CAC suggests codes for human review while autonomous coding assigns codes without human intervention (Correct answer)

Correct answer: CAC suggests codes for human review while autonomous coding assigns codes without human intervention

CAC uses NLP to suggest codes for review by a human coder, while autonomous coding assigns codes automatically without human review.

Question 70: Which Z code category is used to capture screening examinations for conditions in patients with no signs or symptoms?

Z00–Z13 (Encounters for examinations) (Correct answer)
Z55–Z65 (Social determinants)
Z23 (Immunizations)
Z77–Z99 (Health hazard status)

Correct answer: Z00–Z13 (Encounters for examinations)

ICD-10-CM Z00–Z13 includes codes for routine and screening examinations in asymptomatic patients.

Question 71: What is the purpose of E/M code leveling?

To assign the appropriate code level based on medical decision-making complexity or total time (Correct answer)
To determine physician scheduling
To determine nurse staffing ratios
To rank hospitals by quality

Correct answer: To assign the appropriate code level based on medical decision-making complexity or total time

E/M leveling involves selecting the appropriate service level based on MDM complexity or total time.

Question 72: How should an HIM manager handle a team consistently not meeting coding productivity standards?

Immediately terminate underperforming staff
Ignore the problem
Double the productivity requirement
Investigate root causes through data analysis and staff input, then implement targeted solutions (Correct answer)

Correct answer: Investigate root causes through data analysis and staff input, then implement targeted solutions

An effective manager investigates underlying causes before implementing targeted solutions.

Question 73: Which type of system test verifies that new or modified software functions correctly after updates without breaking existing functionality?

Regression testing (Correct answer)
Integration testing
Stress testing
User acceptance testing (UAT)

Correct answer: Regression testing

Regression testing re-runs previously passing tests after changes to confirm that existing features still work correctly.

Question 74: What is the purpose of chargemaster (CDM) maintenance?

To manage the vehicle fleet
To regularly review and update all billable services to ensure accurate pricing, current codes, and compliance (Correct answer)
To maintain the building
To maintain employee records

Correct answer: To regularly review and update all billable services to ensure accurate pricing, current codes, and compliance

CDM maintenance involves regular review of all billable items for accurate descriptions, current codes, and appropriate prices.

Question 75: What is the purpose of the Recovery Audit Contractor (RAC) program?

To recruit healthcare workers
To help patients recover from illness
To recover stolen equipment
To identify and recover improper Medicare payments through post-payment claim reviews (Correct answer)

Correct answer: To identify and recover improper Medicare payments through post-payment claim reviews

RACs review Medicare claims post-payment to identify both overpayments and underpayments.

Question 76: A facility's incomplete record rate is consistently above benchmark. Which policy change would MOST directly address this problem?

Increase the number of HIM staff assigned to coding
Reduce the legal medical record definition
Require nurses to complete physician documentation
Implement suspension of clinical privileges for physicians with delinquent records (Correct answer)

Correct answer: Implement suspension of clinical privileges for physicians with delinquent records

Suspending clinical privileges for physicians with delinquent records is the most effective enforcement mechanism recognized by accreditation bodies.

Question 77: An outpatient facility's size is decided by its?

licensed beds.
square feet of facility.
bed count.
visits/encounters per day. (Correct answer)

Correct answer: visits/encounters per day.

The size of an outpatient facility, such as a physical therapy center, is defined by the visits or contacts each day because outpatients often do not stay for extended periods of time; hence, size is efficiency-based. Therefore, regardless of the physical size of the facility, the number of beds, or other pieces of equipment available, a facility that serves 200 patients per day is double the size of one that serves 100 patients per day.

Question 78: Under the HIPAA Breach Notification Rule, covered entities must notify affected individuals of a breach within:

60 days of the end of the calendar year
60 days of discovery (Correct answer)
30 days of discovery
15 days of discovery

Correct answer: 60 days of discovery

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovering a breach.

Question 79: Under the MS-DRG system, what is the primary factor that determines a patient's DRG assignment?

Number of procedures performed
Attending physician specialty
Principal diagnosis with complications/comorbidities (CCs/MCCs) (Correct answer)
Length of stay

Correct answer: Principal diagnosis with complications/comorbidities (CCs/MCCs)

MS-DRG assignment is driven primarily by the principal diagnosis and the presence of complications or comorbidities (CC/MCC) that affect resource use.

Question 80: What is the primary function of the Uniform Hospital Discharge Data Set (UHDDS)?

To define a minimum set of data elements collected at discharge for inpatient stays (Correct answer)
To track emergency department wait times
To establish coding guidelines for outpatient visits
To standardize financial reporting

Correct answer: To define a minimum set of data elements collected at discharge for inpatient stays

The UHDDS defines the core minimum data elements that should be collected for every inpatient hospital discharge.

Question 81: When calculating a hospital's infection rate, which formula is correct?

(Number of infections / Number of admissions) × 100
(Number of infections / Total discharges) × 100 (Correct answer)
(Number of infections / Staffed beds) × 100
(Number of infections / Total inpatient service days) × 1,000

Correct answer: (Number of infections / Total discharges) × 100

Hospital infection rate is calculated as the number of infections divided by total discharges, multiplied by 100.

Question 82: A hospital is transitioning from a hybrid record system to a fully electronic health record (EHR). To manage this significant change and overcome potential staff resistance, which of the following is the most critical activity for the HIM leadership to undertake?

Mandate the use of the new system with strict penalties for non-compliance.
Establish clear communication channels and involve staff in the implementation process. (Correct answer)
Outsource the entire scanning and indexing process to a third-party vendor.
Focus training only on the most technologically skilled employees.

Correct answer: Establish clear communication channels and involve staff in the implementation process.

Successful change management relies heavily on communication and employee buy-in. Involving staff in the process (e.g., through super-user programs or feedback sessions) and maintaining clear, consistent communication about the reasons for the change, the timeline, and the benefits can significantly reduce resistance and improve adoption.

Question 83: What is the purpose of risk adjustment in healthcare outcome reporting?

To allow fair comparison of outcomes across facilities with different patient populations (Correct answer)
To reduce the number of variables tracked in a clinical study
To increase reimbursement rates for high-risk patients
To eliminate all patient-related variables from the dataset

Correct answer: To allow fair comparison of outcomes across facilities with different patient populations

Risk adjustment accounts for differences in patient severity and demographics so that outcomes across facilities can be fairly compared.

Question 84: What is the significance of 'upcoding' in clinical documentation?

It refers to updating outdated ICD codes to current versions
It describes querying physicians for higher-specificity diagnoses
It is a best practice for maximizing CDI efficiency
It is a fraudulent practice of coding a more expensive service than documented (Correct answer)

Correct answer: It is a fraudulent practice of coding a more expensive service than documented

Upcoding is an illegal practice that involves billing for a higher-paying service or diagnosis than what is actually documented or performed.

Question 85: Which of the following is a characteristic of the problem-oriented medical record (POMR)?

Care is organized around a numbered problem list with SOAP-format progress notes (Correct answer)
Records are maintained exclusively in electronic format
Documents are organized by the department that created them
All entries are arranged in reverse chronological order

Correct answer: Care is organized around a numbered problem list with SOAP-format progress notes

The POMR uses a numbered problem list as an index, and progress notes are written in SOAP (Subjective, Objective, Assessment, Plan) format for each problem.

Question 86: What is the first step in the healthcare revenue cycle?

Accounts receivable follow-up
Claims submission
Payment posting
Patient pre-registration and scheduling including insurance verification (Correct answer)

Correct answer: Patient pre-registration and scheduling including insurance verification

The revenue cycle begins with pre-registration, insurance verification, and eligibility confirmation.

Question 87: Which documentation is required to code a surgical complication in an inpatient record?

The operative report alone
Any abnormal lab value post-surgery
Nursing notes indicating patient discomfort
Physician documentation linking the condition to the surgical procedure (Correct answer)

Correct answer: Physician documentation linking the condition to the surgical procedure

Coding guidelines require explicit physician documentation establishing a cause-and-effect relationship between a procedure and a complication before a complication code may be assigned.

Question 88: A hospital has a licensed bed count of 250. For a particular 24-hour period, the inpatient census taken at midnight was 200. What was the inpatient bed occupancy rate for that day?

50%
125%
80% (Correct answer)
20%

Correct answer: 80%

The inpatient bed occupancy rate is calculated by dividing the number of occupied beds (the inpatient census) by the total number of available licensed beds, then multiplying by 100 to get a percentage. The calculation is (200 / 250) * 100 = 80%.

Question 89: What does EMTALA require of hospitals with emergency departments?

To provide free care to all patients
To maintain 24-hour surgical coverage
To provide a medical screening exam and stabilizing treatment regardless of ability to pay (Correct answer)
To accept all insurance plans

Correct answer: To provide a medical screening exam and stabilizing treatment regardless of ability to pay

EMTALA requires hospitals with EDs to provide a medical screening examination and stabilizing treatment to all individuals.

Question 90: Which of the following best describes a hybrid health record?

A record accessible by both inpatient and outpatient providers
A record that uses two different EHR vendor systems
A record that contains both paper and electronic components (Correct answer)
A record stored on two separate servers for redundancy

Correct answer: A record that contains both paper and electronic components

A hybrid health record is one in which documentation exists in both paper and electronic formats during a transition to a fully electronic system.

Question 91: A hospital's HIM department is reorganized to include a project manager who reports to both the HIM director and the IT director simultaneously. This describes which organizational structure?

Matrix structure (Correct answer)
Functional structure
Flat structure
Line structure

Correct answer: Matrix structure

A matrix structure allows employees to report to two or more managers, typically combining functional and project-based authority.

Question 92: A release of information (ROI) specialist receives a request for records from a patient's neighbor claiming to be a caregiver. What should the specialist do?

Release only the diagnosis summary
Release the records since the neighbor stated they are a caregiver
Require a signed authorization from the patient or documented legal authority before releasing (Correct answer)
Contact the treating physician to obtain verbal approval

Correct answer: Require a signed authorization from the patient or documented legal authority before releasing

Without a signed patient authorization or documented legal authority such as a healthcare proxy, records may not be released to third parties regardless of their stated relationship.

Question 93: Which reimbursement methodology groups inpatient hospital cases into payment categories based on principal diagnosis, procedures, and other factors for Medicare payment?

Diagnosis-Related Groups (DRGs) (Correct answer)
Resource-Based Relative Value Scale (RBRVS)
Resource Utilization Groups (RUGs)
Ambulatory Payment Classifications (APCs)

Correct answer: Diagnosis-Related Groups (DRGs)

DRGs are used under the Inpatient Prospective Payment System (IPPS) to reimburse acute care hospitals a fixed amount based on how a patient's case is grouped according to diagnosis, procedures, age, and discharge status.

Question 94: What does the ICD-10-CM Excludes1 note mean?

The two conditions cannot occur together and the excluded code should never be used with this code (Correct answer)
The excluded code may be used together with this code if both are documented
The excluded code is a different condition but may coexist
The excluded code is an alternative code for the same condition

Correct answer: The two conditions cannot occur together and the excluded code should never be used with this code

Excludes1 means the excluded condition cannot coexist with the code and should not be coded together.

Question 95: What is the HIM department's role in managing the transition from paper to electronic health records?

HIM is responsible for purchasing hardware only
HIM has no role
HIM only handles paper storage
HIM leads legal health record definition, develops document management policies, oversees scanning, and ensures regulatory compliance (Correct answer)

Correct answer: HIM leads legal health record definition, develops document management policies, oversees scanning, and ensures regulatory compliance

HIM plays a central role in defining the legal health record, establishing policies, and ensuring compliance throughout the transition.

Question 96: A patient requests amendment of their medical record, claiming a diagnosis is incorrect. Under HIPAA, the covered entity may deny the request if:

The information was not created by the covered entity and the originator is available to amend it (Correct answer)
The record was created more than five years ago
The amendment would increase reimbursement
The patient disagrees with the physician's clinical judgment

Correct answer: The information was not created by the covered entity and the originator is available to amend it

HIPAA allows denial of an amendment request if the covered entity did not create the information and the originating entity is reasonably available for the amendment.

Question 97: An RHIT is conducting a review of patient demographic data and finds multiple entries for the same patient with slight variations in the name (e.g., 'Jon Smith', 'John Smith', 'Jonathan Smith'). This issue directly impacts the integrity of the:

Medical Staff Bylaws
Trauma Registry
Master Patient Index (MPI) (Correct answer)
Charge Description Master (CDM)

Correct answer: Master Patient Index (MPI)

The Master Patient Index (MPI) is a database that maintains a unique identifier for each patient seen by a healthcare organization. Duplicate or overlaid records within the MPI compromise data integrity and can lead to significant patient safety and billing errors.

Question 98: Which type of code would be utilized in HCPCS level II for medications that are not taken orally, such as chemotherapy treatments and inhalational medications?

J codes (Correct answer)
D codes
A codes
E codes

Correct answer: J codes

J codes are used in HCPSC level II codes for medications not used orally, such as chemotherapy treatments and inhalation medications. Transportation services like ground and air ambulance are designated with A codes. The American Dental Association (ADA) owns the copyright to the CDT code set, which includes D codes, which are used for dental treatments. E codes are used for durable medical equipment, including oxygen equipment and supplies and bathtub wall rails.

Question 99: A state law grants patients broader access rights to their mental health records than HIPAA provides. Under the principle of federal preemption, which standard applies?

The federal standard applies only for Medicare patients
HIPAA always preempts state law
Neither law applies; the provider uses professional judgment
The state law applies because it provides greater patient protections (Correct answer)

Correct answer: The state law applies because it provides greater patient protections

HIPAA establishes a floor, not a ceiling; state laws providing greater privacy protections or patient rights are not preempted and must be followed.

Question 100: A healthcare facility experiences a data breach affecting 600 patients. Under the HIPAA Breach Notification Rule, within how many days must affected individuals be notified?

60 days (Correct answer)
120 days
30 days
90 days

Correct answer: 60 days

The HIPAA Breach Notification Rule requires notification within 60 days of discovering a breach.

Question 101: A hospital had 2,500 discharges last month with 15,000 discharge days. What is the average length of stay (ALOS)?

6 days (Correct answer)
5 days
7.5 days
10 days

Correct answer: 6 days

ALOS = 15,000 / 2,500 = 6 days.

Question 102: A provider dictates a discharge summary and, upon review, realizes they stated the incorrect dosage for a medication. The electronic health record (EHR) system allows for amendments. What is the proper procedure for correcting this error?

Create an addendum to the original note, clearly stating the correction, the reason for the change, and including the current date and time. (Correct answer)
Delete the original dictated note and re-dictate the entire summary with the correct information.
Overwrite the incorrect dosage in the original note with the correct information.
Notify the IT department to have the original entry purged from the system.

Correct answer: Create an addendum to the original note, clearly stating the correction, the reason for the change, and including the current date and time.

The proper procedure for correcting an error in an EHR is to create a dated and signed addendum that clarifies the incorrect information. The original entry should not be deleted or overwritten to maintain the integrity of the legal health record and provide a clear audit trail.

Question 103: A claim is denied because the procedure code does not match the diagnosis code. This is an example of which type of edit?

Medically unlikely edit (MUE)
Duplicate claim edit
Medical necessity edit
National Correct Coding Initiative (NCCI) edit (Correct answer)

Correct answer: National Correct Coding Initiative (NCCI) edit

NCCI edits prevent improper payment of procedures that should not be billed together or when a procedure is incompatible with the diagnosis.

Question 104: What is the primary purpose of a confidence interval in healthcare statistics?

To calculate the exact true population parameter
To identify outliers in a dataset
To determine statistical significance between two groups
To express the range within which the true value likely falls (Correct answer)

Correct answer: To express the range within which the true value likely falls

A confidence interval provides a range of values within which the true population parameter is likely to fall with a specified level of certainty.

Question 105: A hospital adopts standardized clinical terminologies such as SNOMED CT and LOINC for data capture. Which data quality goal is PRIMARILY supported by this decision?

Enabling consistent and interoperable data exchange (Correct answer)
Reducing storage costs across clinical systems
Speeding up the release-of-information process
Eliminating the need for physician query programs

Correct answer: Enabling consistent and interoperable data exchange

Standardized terminologies ensure that the same concept is represented the same way across different systems and organizations, promoting consistency and interoperability. This is fundamental to data integrity when records are shared across care settings.

Question 106: What is the purpose of a case mix index (CMI) in hospital administration?

To count total patient cases
To determine the hospital's geographic service area
To measure the average relative weight of cases treated, reflecting complexity and resource intensity (Correct answer)
To track patient satisfaction

Correct answer: To measure the average relative weight of cases treated, reflecting complexity and resource intensity

CMI represents the average relative weight of DRGs for all cases treated, reflecting overall complexity.

Question 107: What is the purpose of the 'Table of Neoplasms' in the ICD-10-CM index?

To guide coders to the correct code based on site and behavior (malignant, benign, uncertain, etc.) (Correct answer)
To cross-reference CPT oncology codes
To list all cancers by body system only
To provide staging information for tumors

Correct answer: To guide coders to the correct code based on site and behavior (malignant, benign, uncertain, etc.)

The Table of Neoplasms organizes codes by anatomic site and neoplasm behavior, directing coders to the appropriate code.

Question 108: Role-based access control (RBAC) in an EHR system grants permissions based on:

Individual user identity only
The sensitivity of the data requested
The user's job function or title (Correct answer)
The time of day the system is accessed

Correct answer: The user's job function or title

RBAC assigns system access privileges according to a user's defined role or job function within the organization.

Question 109: Data 'currency' (also called timeliness) is most critical in which of the following situations?

Alerting a physician to a critical lab value (Correct answer)
Archiving historical discharge summaries
Running an annual coding productivity report
Generating a five-year trend analysis of DRG weights

Correct answer: Alerting a physician to a critical lab value

Timeliness is most critical when a delay in data availability could affect clinical decision-making or patient safety.

Question 110: What is a prior authorization?

A physician's order for medication
Authorization from a patient's family
Authorization to access a medical record
A requirement to obtain health plan approval before providing certain services (Correct answer)

Correct answer: A requirement to obtain health plan approval before providing certain services

Prior authorization requires health plan approval before specific services are provided, verifying medical necessity.

Question 111: A hospital discovers that an unencrypted laptop containing the protected health information (PHI) of 600 patients was stolen. According to the HITECH Act Breach Notification Rule, which of the following actions is required?

Wait for a law enforcement investigation to conclude before notifying any parties.
Notify affected individuals, the Secretary of HHS, and prominent media outlets within 60 days. (Correct answer)
Report the breach to the Secretary of HHS on an annual basis with other small breaches.
Notify only the affected individuals within 60 days of discovering the breach.

Correct answer: Notify affected individuals, the Secretary of HHS, and prominent media outlets within 60 days.

The HITECH Act Breach Notification Rule requires covered entities to notify affected individuals, the Secretary of HHS, and prominent media outlets serving the relevant state or jurisdiction without unreasonable delay, and in no case later than 60 calendar days, following the discovery of a breach affecting more than 500 individuals.

Question 112: A patient's record shows a blood glucose of 450 mg/dL and the physician documents 'hyperglycemia.' A CDI specialist queries for diabetes mellitus with hyperglycemia. This query is appropriate because:

Hyperglycemia is always synonymous with diabetes
The coder wants to increase the DRG weight
The physician must document diabetes for billing purposes
Clinical indicators in the record support a more specific diagnosis (Correct answer)

Correct answer: Clinical indicators in the record support a more specific diagnosis

When clinical indicators such as lab values support a more specific diagnosis, a compliant query may be submitted to the physician for clarification.

Question 113: A physician documents a progress note using a copy-paste function from a previous day's note without updating the clinical information. This practice is MOST problematic because it:

Violates physician credentialing requirements
May introduce inaccurate or outdated information into the current record (Correct answer)
Creates a source-oriented record format
Increases documentation time unnecessarily

Correct answer: May introduce inaccurate or outdated information into the current record

Copy-paste or 'cloning' documentation risks perpetuating outdated or inaccurate clinical information, which can harm patient safety and coding accuracy.

Question 114: Which FHIR resource type would be used to represent a patient's documented allergy to penicillin?

MedicationStatement
AllergyIntolerance (Correct answer)
Condition
Observation

Correct answer: AllergyIntolerance

The FHIR AllergyIntolerance resource is specifically designed to capture a patient's risk of adverse reaction to a substance.

Question 115: A facility's record destruction policy calls for shredding paper records. Which additional step is required to properly document this process?

Archiving a photocopy of each destroyed record
Notifying each patient whose records are destroyed
Obtaining court approval before destroying any records
Maintaining a certificate of destruction that lists what was destroyed, when, and by whom (Correct answer)

Correct answer: Maintaining a certificate of destruction that lists what was destroyed, when, and by whom

A certificate of destruction provides a legal record that documents the destruction process, protecting the facility from liability.

Question 116: In ICD-10-CM, what is the significance of a 7th character 'A' in injury codes?

Accidental cause
Sequela
Subsequent encounter
Initial encounter — active treatment phase (Correct answer)

Correct answer: Initial encounter — active treatment phase

The 7th character 'A' denotes the initial encounter when the patient is receiving active treatment for the injury.

Question 117: A facility transitions from paper to electronic records. During this period, which challenge is MOST critical for HIM professionals to manage?

Converting all paper records to DICOM format
Training staff on ICD-10-CM coding updates
Ensuring record integrity and accessibility across both formats (Correct answer)
Negotiating EHR vendor contracts

Correct answer: Ensuring record integrity and accessibility across both formats

During a hybrid transition, maintaining record integrity and ensuring all patient information is accessible regardless of format is the most critical HIM responsibility.

Question 118: What is the purpose of a clinical documentation improvement (CDI) program?

To reduce the number of pages in medical records
To train physicians on using EHR systems
To ensure complete and accurate documentation that reflects patient acuity and supports proper coding (Correct answer)
To eliminate paper records

Correct answer: To ensure complete and accurate documentation that reflects patient acuity and supports proper coding

CDI programs work to ensure clinical documentation accurately reflects severity of illness and complexity of care.

Question 119: What is the primary purpose of the National Correct Coding Initiative (NCCI) edits?

To prevent improper payment of procedure code combinations that should not be reported together (Correct answer)
To establish physician credentialing requirements
To standardize patient intake forms
To define minimum staffing requirements

Correct answer: To prevent improper payment of procedure code combinations that should not be reported together

NCCI edits identify pairs of CPT/HCPCS codes that should not typically be reported together on the same claim.

Question 120: A health information system's ability to exchange and use information with other systems is best described as:

Redundancy
Interoperability (Correct answer)
Modularity
Scalability

Correct answer: Interoperability

Interoperability is the capacity of different systems to exchange, interpret, and use shared health information effectively.

Question 121: Which ambulatory payment classification (APC) system is used to reimburse Medicare outpatient hospital services?

Prospective Payment System (PPS) for SNFs
Inpatient Prospective Payment System (IPPS)
Outpatient Prospective Payment System (OPPS) (Correct answer)
Resource-Based Relative Value Scale (RBRVS)

Correct answer: Outpatient Prospective Payment System (OPPS)

OPPS groups outpatient services into APCs and pays a predetermined rate per APC, used by Medicare for hospital outpatient reimbursement.

Question 122: Which budgeting approach requires managers to justify every expense from zero each fiscal year, regardless of prior budget allocations?

Activity-based budgeting
Zero-based budgeting (Correct answer)
Capital budgeting
Incremental budgeting

Correct answer: Zero-based budgeting

Zero-based budgeting requires justification of all expenditures from scratch each year rather than using the prior year's budget as a baseline.

Question 123: Which of the following is a key responsibility of the HIM department regarding release of information (ROI)?

Setting hospital admission policies
Verifying the validity of authorizations and ensuring only authorized information is disclosed (Correct answer)
Deciding which treatments a patient should receive
Determining insurance coverage

Correct answer: Verifying the validity of authorizations and ensuring only authorized information is disclosed

The HIM department is responsible for verifying that all release of information requests include valid authorization.

Question 124: In healthcare analytics, what does 'sensitivity' of a diagnostic test measure?

The probability that a positive test result is truly positive
The proportion of the population that has the disease
The probability that a negative test result is truly negative
The proportion of true positives correctly identified by the test (Correct answer)

Correct answer: The proportion of true positives correctly identified by the test

Sensitivity measures a test's ability to correctly identify those who have the disease (true positive rate).

Question 125: What is the difference between a 'clean claim' and a 'rejected claim'?

Clean claims are for Medicare
There is no difference
A clean claim has all required data and processes smoothly; a rejected claim has errors preventing processing (Correct answer)
Clean claims are on white paper

Correct answer: A clean claim has all required data and processes smoothly; a rejected claim has errors preventing processing

A clean claim contains all required information for processing; a rejected claim has errors or missing data.

Question 126: What is the correct sequencing when a patient is admitted for chemotherapy?

The chemotherapy encounter code (Z51.11) is the principal diagnosis, followed by the neoplasm code (Correct answer)
The neoplasm is sequenced first
Only the neoplasm code is assigned
Only the chemotherapy code is assigned

Correct answer: The chemotherapy encounter code (Z51.11) is the principal diagnosis, followed by the neoplasm code

When admitted solely for chemotherapy, the Z code is the principal diagnosis with the neoplasm as secondary.

Question 127: What is 'span of control' in healthcare organizational design?

The hospital's geographic service area
The number of employees a manager can effectively supervise (Correct answer)
The hours of operation
The range of services offered

Correct answer: The number of employees a manager can effectively supervise

Span of control defines the number of subordinates reporting directly to a manager.

Question 128: A hospital reports 25 deaths among 500 surgical patients in a year. What is the surgical death rate?

5% (Correct answer)
25%
10%
2%

Correct answer: 5%

Surgical death rate = (25 / 500) x 100 = 5%.

Question 129: According to the UHDDS, the definition of Principal Diagnosis is the condition that:

is the most resource-intensive during the hospital stay.
is established after study to be chiefly responsible for the patient's admission to the hospital. (Correct answer)
is the first diagnosis documented by the admitting physician in the emergency department.
is the underlying cause of a manifestation, coded second.

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

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 130: Which accreditation body publishes the Comprehensive Accreditation Manual for Hospitals (CAMH) which includes medical record standards?

The Joint Commission (TJC) (Correct answer)
American Health Information Management Association (AHIMA)
Centers for Medicare & Medicaid Services (CMS)
National Committee for Quality Assurance (NCQA)

Correct answer: The Joint Commission (TJC)

The Joint Commission publishes the CAMH, which sets medical record content and completion standards for accredited hospitals.

Question 131: A hospital's coding team notices that certain diagnosis codes are never used despite being clinically relevant for their patient population. This may indicate a problem with:

Data granularity of the lab interface
Data accessibility for remote coders
Data completeness in code assignment (Correct answer)
Data currency of the billing system

Correct answer: Data completeness in code assignment

Underuse of relevant codes suggests that conditions are not being captured in the documentation or coding process, reducing completeness.

Question 132: Which leadership style involves the manager making decisions without input from team members?

Laissez-faire leadership
Democratic leadership
Transformational leadership
Autocratic (authoritarian) leadership (Correct answer)

Correct answer: Autocratic (authoritarian) leadership

Autocratic leadership is characterized by the leader making decisions independently.

Question 133: What is a 'CC' (complication or comorbidity) in the context of MS-DRG assignment?

Any documented chronic disease
A principal diagnosis that requires surgical intervention
A laboratory finding noted in the record
A secondary diagnosis that substantially increases hospital resource use (Correct answer)

Correct answer: A secondary diagnosis that substantially increases hospital resource use

CCs are secondary diagnoses that increase resource consumption and affect MS-DRG grouping and hospital reimbursement.

Question 134: Under the HIPAA Minimum Necessary standard, a request for PHI from another treating provider should be:

Routed through the hospital's legal department first
Denied unless the patient is present to authorize
Limited to only the information reasonably needed to accomplish the treatment purpose (Correct answer)
Honored with the full record since treatment is a permitted purpose

Correct answer: Limited to only the information reasonably needed to accomplish the treatment purpose

Even for permitted treatment purposes, the Minimum Necessary standard requires limiting disclosure to what is reasonably needed for that specific purpose.

Question 135: Which coding system is used to report inpatient hospital procedures in the United States?

CPT
SNOMED CT
ICD-10-PCS (Correct answer)
HCPCS Level II

Correct answer: ICD-10-PCS

ICD-10-PCS is the official coding system for reporting inpatient hospital procedures in the United States.

Question 136: When coding neoplasm-related encounters, which sequencing rule applies when a patient is admitted solely to receive chemotherapy for a known malignancy?

Sequence the malignancy as the principal diagnosis and chemotherapy as secondary
Sequence the neoplasm-related pain as the principal diagnosis
Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis and the malignancy as an additional code (Correct answer)
Sequence an adverse effect code as the principal diagnosis

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

Per ICD-10-CM Official Guidelines, when the sole reason for admission is to receive antineoplastic chemotherapy, the Z code for the encounter (Z51.11) is the principal diagnosis, with the malignancy coded additionally.

Question 137: A business associate agreement (BAA) is required when a vendor performs which type of function?

Delivers office supplies to a clinic
Processes PHI on behalf of a covered entity (Correct answer)
Maintains the parking lot of a hospital
Provides legal services unrelated to PHI

Correct answer: Processes PHI on behalf of a covered entity

A BAA is required when a vendor creates, receives, maintains, or transmits PHI on behalf of a covered entity.

Question 138: What is the difference between 'assignment' and 'non-assignment' in Medicare billing?

There is no difference for patients
Assignment means Medicare pays more
Assignment means assigning a family member
Assignment means accepting Medicare's allowed amount as full payment; non-assignment allows billing up to 115% of the fee schedule (Correct answer)

Correct answer: Assignment means accepting Medicare's allowed amount as full payment; non-assignment allows billing up to 115% of the fee schedule

Participating providers accept the allowed amount; non-participating providers can charge up to the limiting charge.

Question 139: How soon after a claim denial from an insurance like Blue Cross/Blue Shield must an internal appeal be filed?

180 (Correct answer)
30
60
90

Correct answer: 180

If an insurer, such as Blue Cross/Blue Shield, rejects a claim, the insurance company must file an internal appeal within 180 days following the rejection. For services to be provided in the future, the insurance provider must finish the appeals process and make a determination within 30 days, and for services previously rendered, within 60 days. The claimant has 60 days following notification of the denial to obtain an external review by a third party if the insurer continues to decline the claim.

Question 140: A modifier -25 is appended to an E/M code on the same day as a minor procedure. What does this indicate?

A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure (Correct answer)
The E/M service was provided by a different physician
The procedure was bilateral
The E/M was a pre-operative evaluation only

Correct answer: A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure

Modifier -25 signals that the E/M service was distinct from the procedure and warrants separate reimbursement.

Question 141: During a routine chart review, an RHIT discovers that a nurse's signature is missing from a paper-based medication administration record that has already been scanned into the EHR. What is the appropriate action to take?

Ignore the missing signature as the record is already electronic.
Follow the facility's policy for late entries or amendments to authenticate the entry. (Correct answer)
Add a digital note to the image stating the signature is missing.
Delete the scanned image and ask the nurse to sign a blank form.

Correct answer: Follow the facility's policy for late entries or amendments to authenticate the entry.

A missing signature is a documentation deficiency. The correct procedure is to follow the established facility policy for authenticating records after the fact, which typically involves the original author signing and dating the entry as a late entry or addendum. This maintains the integrity of the original record while correcting the omission. Simply deleting the image or ignoring the issue would be inappropriate and could have legal consequences.

Question 142: What is the purpose of Six Sigma in healthcare?

To standardize employee uniforms
To increase patient volume
To reduce variation and defects through a structured data-driven approach improving quality and efficiency (Correct answer)
To eliminate quality monitoring

Correct answer: To reduce variation and defects through a structured data-driven approach improving quality and efficiency

Six Sigma aims to reduce process variation and defects through the DMAIC framework.

Question 143: An attorney presents a subpoena duces tecum for a patient's medical records for a civil lawsuit. The subpoena is not accompanied by a court order or patient authorization. What is the most appropriate initial action for the HIM professional?

Release the records immediately to comply with the legal document.
Do not release the records until 'satisfactory assurances' are met or a court order is provided. (Correct answer)
Release a limited summary of the record under the 'minimum necessary' principle.
Contact the patient by phone to obtain verbal consent for the release.

Correct answer: Do not release the records until 'satisfactory assurances' are met or a court order is provided.

Under HIPAA, a subpoena that is not signed by a judge (i.e., not a court order) is insufficient on its own to compel the release of PHI. The covered entity must first receive 'satisfactory assurances' from the party seeking the information that reasonable efforts were made to notify the patient of the request or that a qualified protective order has been secured. Without these assurances, a court order, or a valid patient authorization, the records cannot be released.

Question 144: Which measure of central tendency is most appropriate when data contains extreme outliers?

Median (Correct answer)
Mean
Range
Mode

Correct answer: Median

The median is not affected by extremely high or low values.

Question 145: A coder files a formal complaint alleging that she is being paid less than male coders with the same qualifications and job duties. Which federal law is most relevant to this complaint?

Age Discrimination in Employment Act
Americans with Disabilities Act
Title VII of the Civil Rights Act
Equal Pay Act of 1963 (Correct answer)

Correct answer: Equal Pay Act of 1963

The Equal Pay Act of 1963 prohibits wage discrimination based on sex for employees performing substantially equal work in the same establishment.

Question 146: A health information manager discovers that clinical documentation in the EHR is frequently backdated by nursing staff to meet charting deadlines. Which data quality characteristic is most directly compromised?

Completeness
Accuracy
Consistency
Timeliness (Correct answer)

Correct answer: Timeliness

Timeliness requires that data be recorded promptly when the event occurs. Backdating documentation violates this principle by misrepresenting when care was actually provided, even if the content itself is accurate.

Question 147: What CPT modifier indicates that a service or procedure was distinct or independent from other services performed on the same day?

-59 (Correct answer)
-51
-25
-76

Correct answer: -59

Modifier -59 identifies procedures not normally reported together but appropriate under specific circumstances on the same date.

Question 148: An organization is implementing a new EHR and needs to migrate data from the legacy system. Which step is most critical before migration?

Training staff on the new system only
Conducting thorough data cleansing and mapping to ensure legacy data meets the new system's standards (Correct answer)
Deleting all old records
Printing all records

Correct answer: Conducting thorough data cleansing and mapping to ensure legacy data meets the new system's standards

Data cleansing and mapping before migration ensures legacy data is cleaned, standardized, and properly mapped.

Question 149: Which of the following is an example of a compliant physician query format?

A verbal-only query with no documentation
A query presenting multiple clinically supported options including 'other' and 'undetermined' (Correct answer)
A query sent to a non-treating provider
A leading query that suggests a specific diagnosis

Correct answer: A query presenting multiple clinically supported options including 'other' and 'undetermined'

Compliant queries are non-leading, present multiple supported options, and include clinical indicators to guide physician response.

Question 150: Which of the following is an example of a secondary data source in healthcare?

A patient's medical record
A disease registry (Correct answer)
A consent form
A physician's progress notes

Correct answer: A disease registry

Disease registries are secondary data sources because they derive information from primary sources and organize it for specific purposes.

Question 151: Which document sent by the payer details what was paid, denied, or adjusted on a claim?

Medicare Summary Notice (MSN)
Advance Beneficiary Notice (ABN)
Explanation of Benefits (EOB) / Remittance Advice (RA) (Correct answer)
Notice of Claim Adjudication (NCA)

Correct answer: Explanation of Benefits (EOB) / Remittance Advice (RA)

The EOB/RA is the document payers send to providers detailing payment decisions, adjustments, and denial reasons for submitted claims.

RHIT (Registered Health Information Technician) Exam

The RHIT (Registered Health Information Technician) Exam exam validates essential knowledge and skills required for certification or licensure in this field.

150

Questions

200 min

Time Limit

70%

To Pass

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