- Registered Health Information Technician Medical Coding Principles Flashcards
6 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
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What is the correct definition of the 'principal diagnosis' in inpatient coding?
Answer: The condition established after study to be chiefly responsible for occasioning the admission
The principal diagnosis is the condition chiefly responsible for the admission, determined after study.
In ICD-10-CM, what is the purpose of the seventh character?
Answer: To provide additional information such as the type of encounter (initial, subsequent, or sequela)
The seventh character commonly indicates initial (A), subsequent (D), or sequela (S) encounter type.
What is the difference between a CC and an MCC in the MS-DRG system?
Answer: An MCC represents a more severe secondary condition with greater impact on resource utilization and higher-weighted DRG
MCCs represent conditions with higher severity and greater resource consumption impact.
When coding an outpatient encounter without a definitive diagnosis, what should the coder assign?
Answer: Signs and symptoms codes that are documented and relevant
In outpatient settings, uncertain diagnoses are coded using signs and symptoms, not probable or suspected conditions.
What is the purpose of CPT modifiers?
Answer: To provide additional information about circumstances without changing the code's definition
CPT modifiers indicate that a service was altered by specific circumstances without changing its basic definition.
What is unbundling in medical coding and why is it a compliance concern?
Answer: Fraudulently billing separately for services that should be reported under a single comprehensive code
Unbundling is billing component services separately when a comprehensive code should be used, resulting in inappropriate higher reimbursement.