RHIT Final Practice Question and Answers with multiple
answers choices
Which of the following would be considered abuse in terms of healthcare
reimbursement?
a. Billing for services not provided to the patient
b. A pattern of coding errors
c. Misrepresentation of procedures performed to obtain payment for non-covered
services
d. Falsifying a patient's diagnosis to justify tests *** A pattern of coding errors
A single coding error is not abuse; a pattern of the same error makes it abuse (Foltz et
al. 2016, 448).
To stay current with new technologies and pioneering procedures, CPT is revised each
year, with changes going into effect the following:
a. Janaury 1st
b. April 1st
c. July 1st
d. October 1st *** Jan 1st
The CPT Editorial Research and Development Department supports the modification
process for the code set. To stay current with new technologies and pioneering
procedures, CPT is revised each year, with changes going into effect the following
January 1 (Casto 2018, 28).
Why is only the most current version of a document displayed?
a. All previous versions are deleted
b. The user decides which version to see
c. To ensure there is no confusion on the correct document
d. Only the physician has access to previous versions of a document *** To ensure
there is no confusion on the correct document
Version control identifies which version(s) of the documents is available to the user. All
versions must be maintained but access to all except the current version should be
controlled so that there is no confusion about which version is correct (Sayles 2016b,
69).
Which of the following is a key feature of a problem-oriented health record?
a. Chronological list of solved problems
b. Itemized list of patient's present and past conditions
,c. Itemized list of patient's present conditions
d. Sequential list of patient's confirmed diagnoses *** Itemized list of patient's present
and past conditions
The HIM department is having an issue with extensive use of sick leave within the
department, and quality of work has declined. The HIM manager decides to personally
ask each employee in the department what they believe is leading to the problem with
extensive use of sick leave. The HIM manager uses this information to create a new
sick leave policy in an effort to improve the quality of work performed in the department.
What technique is the HIM manager using to address the sick leave and quality of work
issue?
a. Exclusive
b. Facilitative
c. Functional
d. Inclusive *** Inclusive
Rationale: Encouraging team productivity can be a major issue in many organizations.
This is an outgrowth of the two common management styles used by most
organizations. One style is inclusive: all viewpoints are considered with respect to their
potential contribution to solving the PI issue at hand. The other style is exclusive: its
goal is to get to a result as quickly as possible. Each style has positive and negative
aspects (Shaw and Carter 2019, 60).
The hospitals public relations department in conjunction with the local high school is
holding a job-shadowing day. The purpose of this event is to give high school seniors an
opportunity to observe the various jobs in the hospital and help them with career
planning. The public relations department asks for event input from the standpoint of
HIPAA compliance. In this case, what should the HIM department advise?
a. Job shadowing is specifically prohibited by HIPAA.
b. Job shadowing is allowed by HIPAA under the provision allowing students and
trainees to practice.
c. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is
very limited, such as administrative areas.
d. Job shadowing is allowed by HIPAA under the provision of volunteers. *** Job
shadowing should be limited to areas in which the likelihood of exposure to PHI is very
limited, such as administrative areas.
Job shadowing should be limited to areas where the likelihood of exposure to PHI is
very limited, such as in administrative areas. There is a provision in the Privacy Rule
that permits students and trainees to practice and improve their skills in the healthcare
environment; however, the context of this provision appears to imply that the students
are already enrolled in a healthcare field of study and that they are under the
supervision of the covered entity. Most covered entities require students to be trained
,on confidentiality and other requirements of the Privacy Rule, and job shadowing
activities do not appear to apply in this exception (Thomason 2013, 41).
When a healthcare organization evaluates their quality measures and patient
satisfaction scores with a similar organization, they are using:
a. Comparative performance data
b. Data repository
c. Information warehouse
d. PI database *** Comparative performance data
To determine if there is a need to collect more data or implement improvement
processes, the data need to be compared to a benchmark, which is a standard of
performance or best practice (Shaw and Carter 2019, 356).
Patient history questionnaires, problem lists, diagnostic test results, and immunization
records are commonly found in which type of health record?
a. Rehabilitative care record
b. Emergency department record
c. Long-term care record
d. Ambulatory record *** Ambulatory record
The ambulatory record is very similar to an inpatient hospital-based health record.
Some of the items included in the ambulatory record are: patient history questionnaires,
problem lists, diagnostic test results, and immunization records (Brickner 2016, 101).
After a claim has been filed with Medicare, a healthcare organization had late charges
posted to a patients outpatient account that changed the calculation of the APC. What is
the best practice for this organization to receive the correct reimbursement from
Medicare?
a. Bill the patient for any remaining balance after payment from Medicare is received.
b. Do nothing because the claim has already been submitted.
c. Return the account to coding for review
d. Submit an adjusted claim to Medicare. *** Submit an adjusted claim to Medicare.
Late charges are any charges that have not been posted to the account number within
the healthcare facility's established bill hold time period. Best practice is four days from
the date of service or discharge. For the provider to be paid for these charges, an
adjusted claim must be sent to Medicare (Schraffenberger and Kuehn 2011, 460).
In performing quantitative analysis of an emergency room health record, which of the
following data elements would the health information technician look for to be present in
the record?
, a. Advance directive, correspondence, anesthesia report
b. Results of tests, consent for treatment, anesthesia report
c. Consent for treatment, advance directive, consent to disclose information
d. Patient identification, time and means of patient arrival, pertinent history of illness ***
Patient identification, time and means of patient arrival, pertinent history of illness
The following information should be entered for each emergency room visit: patient
identification; time and means of arrival to the facility; pertinent history of the illness,
injury, and physical findings; emergency care given prior to arrival; diagnostic and
therapeutic orders; clinical observations; reports and results of procedures and tests;
diagnostic impression; medications administered; conclusions at the termination of
evaluation/treatment; and documentation of cases when the patient leaves against
medical advice (Brickner 2016, 100-101).
A patient is discharged from the hospital with a diagnosis of peptic ulcer versus
cholecystitis, which are both equally treated and well documented. What should the
coder assign as the principal diagnosis?
a. The principal diagnosis must be peptic ulcer
b. The principal diagnosis must be cholecystitis
c. The principal diagnosis can be either peptic ulcer or cholecystitis
d. The coder must query the physician for clarification *** The principal diagnosis can
be either peptic ulcer or cholecystitis
In the unusual instance when two to more diagnoses equally meet the criteria for
principal diagnosis, as determined by the circumstances of admission, diagnostic
workup, and/or the therapy provided, and the alphabetic index, tabular list, or another
coding guideline does not provide sequencing direction in such cases, any one of the
diagnoses may be sequenced first (Schraffenberger and Palkie 2019, 96).
Which database must a healthcare facility query as part of the credentialing process
when a physician initially applies for medical staff privileges?
a. UHDDS
b. NPDB
c. MEDPAR
d. HEDIS *** NPDB
The law requires healthcare facilities to query the National Practitioner Data Bank
(NPDB) as part of the credentialing process. The database should be queried when a
physician initially applies for medical staff privileges and every two years thereafter
(Sharp 2016, 185).
The hospital's Revenue Cycle Management (RCM) team compiles data each month on
the value of discharged not final billed (DNFB) cases. Given the data on this chart, what
action by the HIM department should be taken?
answers choices
Which of the following would be considered abuse in terms of healthcare
reimbursement?
a. Billing for services not provided to the patient
b. A pattern of coding errors
c. Misrepresentation of procedures performed to obtain payment for non-covered
services
d. Falsifying a patient's diagnosis to justify tests *** A pattern of coding errors
A single coding error is not abuse; a pattern of the same error makes it abuse (Foltz et
al. 2016, 448).
To stay current with new technologies and pioneering procedures, CPT is revised each
year, with changes going into effect the following:
a. Janaury 1st
b. April 1st
c. July 1st
d. October 1st *** Jan 1st
The CPT Editorial Research and Development Department supports the modification
process for the code set. To stay current with new technologies and pioneering
procedures, CPT is revised each year, with changes going into effect the following
January 1 (Casto 2018, 28).
Why is only the most current version of a document displayed?
a. All previous versions are deleted
b. The user decides which version to see
c. To ensure there is no confusion on the correct document
d. Only the physician has access to previous versions of a document *** To ensure
there is no confusion on the correct document
Version control identifies which version(s) of the documents is available to the user. All
versions must be maintained but access to all except the current version should be
controlled so that there is no confusion about which version is correct (Sayles 2016b,
69).
Which of the following is a key feature of a problem-oriented health record?
a. Chronological list of solved problems
b. Itemized list of patient's present and past conditions
,c. Itemized list of patient's present conditions
d. Sequential list of patient's confirmed diagnoses *** Itemized list of patient's present
and past conditions
The HIM department is having an issue with extensive use of sick leave within the
department, and quality of work has declined. The HIM manager decides to personally
ask each employee in the department what they believe is leading to the problem with
extensive use of sick leave. The HIM manager uses this information to create a new
sick leave policy in an effort to improve the quality of work performed in the department.
What technique is the HIM manager using to address the sick leave and quality of work
issue?
a. Exclusive
b. Facilitative
c. Functional
d. Inclusive *** Inclusive
Rationale: Encouraging team productivity can be a major issue in many organizations.
This is an outgrowth of the two common management styles used by most
organizations. One style is inclusive: all viewpoints are considered with respect to their
potential contribution to solving the PI issue at hand. The other style is exclusive: its
goal is to get to a result as quickly as possible. Each style has positive and negative
aspects (Shaw and Carter 2019, 60).
The hospitals public relations department in conjunction with the local high school is
holding a job-shadowing day. The purpose of this event is to give high school seniors an
opportunity to observe the various jobs in the hospital and help them with career
planning. The public relations department asks for event input from the standpoint of
HIPAA compliance. In this case, what should the HIM department advise?
a. Job shadowing is specifically prohibited by HIPAA.
b. Job shadowing is allowed by HIPAA under the provision allowing students and
trainees to practice.
c. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is
very limited, such as administrative areas.
d. Job shadowing is allowed by HIPAA under the provision of volunteers. *** Job
shadowing should be limited to areas in which the likelihood of exposure to PHI is very
limited, such as administrative areas.
Job shadowing should be limited to areas where the likelihood of exposure to PHI is
very limited, such as in administrative areas. There is a provision in the Privacy Rule
that permits students and trainees to practice and improve their skills in the healthcare
environment; however, the context of this provision appears to imply that the students
are already enrolled in a healthcare field of study and that they are under the
supervision of the covered entity. Most covered entities require students to be trained
,on confidentiality and other requirements of the Privacy Rule, and job shadowing
activities do not appear to apply in this exception (Thomason 2013, 41).
When a healthcare organization evaluates their quality measures and patient
satisfaction scores with a similar organization, they are using:
a. Comparative performance data
b. Data repository
c. Information warehouse
d. PI database *** Comparative performance data
To determine if there is a need to collect more data or implement improvement
processes, the data need to be compared to a benchmark, which is a standard of
performance or best practice (Shaw and Carter 2019, 356).
Patient history questionnaires, problem lists, diagnostic test results, and immunization
records are commonly found in which type of health record?
a. Rehabilitative care record
b. Emergency department record
c. Long-term care record
d. Ambulatory record *** Ambulatory record
The ambulatory record is very similar to an inpatient hospital-based health record.
Some of the items included in the ambulatory record are: patient history questionnaires,
problem lists, diagnostic test results, and immunization records (Brickner 2016, 101).
After a claim has been filed with Medicare, a healthcare organization had late charges
posted to a patients outpatient account that changed the calculation of the APC. What is
the best practice for this organization to receive the correct reimbursement from
Medicare?
a. Bill the patient for any remaining balance after payment from Medicare is received.
b. Do nothing because the claim has already been submitted.
c. Return the account to coding for review
d. Submit an adjusted claim to Medicare. *** Submit an adjusted claim to Medicare.
Late charges are any charges that have not been posted to the account number within
the healthcare facility's established bill hold time period. Best practice is four days from
the date of service or discharge. For the provider to be paid for these charges, an
adjusted claim must be sent to Medicare (Schraffenberger and Kuehn 2011, 460).
In performing quantitative analysis of an emergency room health record, which of the
following data elements would the health information technician look for to be present in
the record?
, a. Advance directive, correspondence, anesthesia report
b. Results of tests, consent for treatment, anesthesia report
c. Consent for treatment, advance directive, consent to disclose information
d. Patient identification, time and means of patient arrival, pertinent history of illness ***
Patient identification, time and means of patient arrival, pertinent history of illness
The following information should be entered for each emergency room visit: patient
identification; time and means of arrival to the facility; pertinent history of the illness,
injury, and physical findings; emergency care given prior to arrival; diagnostic and
therapeutic orders; clinical observations; reports and results of procedures and tests;
diagnostic impression; medications administered; conclusions at the termination of
evaluation/treatment; and documentation of cases when the patient leaves against
medical advice (Brickner 2016, 100-101).
A patient is discharged from the hospital with a diagnosis of peptic ulcer versus
cholecystitis, which are both equally treated and well documented. What should the
coder assign as the principal diagnosis?
a. The principal diagnosis must be peptic ulcer
b. The principal diagnosis must be cholecystitis
c. The principal diagnosis can be either peptic ulcer or cholecystitis
d. The coder must query the physician for clarification *** The principal diagnosis can
be either peptic ulcer or cholecystitis
In the unusual instance when two to more diagnoses equally meet the criteria for
principal diagnosis, as determined by the circumstances of admission, diagnostic
workup, and/or the therapy provided, and the alphabetic index, tabular list, or another
coding guideline does not provide sequencing direction in such cases, any one of the
diagnoses may be sequenced first (Schraffenberger and Palkie 2019, 96).
Which database must a healthcare facility query as part of the credentialing process
when a physician initially applies for medical staff privileges?
a. UHDDS
b. NPDB
c. MEDPAR
d. HEDIS *** NPDB
The law requires healthcare facilities to query the National Practitioner Data Bank
(NPDB) as part of the credentialing process. The database should be queried when a
physician initially applies for medical staff privileges and every two years thereafter
(Sharp 2016, 185).
The hospital's Revenue Cycle Management (RCM) team compiles data each month on
the value of discharged not final billed (DNFB) cases. Given the data on this chart, what
action by the HIM department should be taken?
