RHIT Practice Test – Health Data Management,
Coding, Information Technology, Compliance and
Revenue Cycle
1. A coder reviews a patient record where the physician has documented ‘possible congestive
heart failure’ in the discharge summary. The patient was admitted for shortness of breath
and treated with diuretics. According to UHDDS guidelines for inpatient coding, how should
the coder proceed?
A. Query the physician to confirm the diagnosis before coding.
B. Code shortness of breath only as the principal diagnosis.
C. Code congestive heart failure as if it were established.
D. Assign a code for an unspecified heart condition.
Correct Answer: C
Explanation: According to the UHDDS, if the diagnosis documented at the time of
discharge is qualified as ‘possible,’ ‘probable,’ or ‘suspected,’ it is coded as if it were
established for inpatient records. This principle ensures that the resources consumed in
treating the suspected condition are captured. A common trap is assuming a query is
always required, but for inpatient settings, these qualifiers are acceptable for final coding if
they are documented at discharge.
,2. An HIM professional is conducting a qualitative analysis of a medical record and notices
that the history and physical (H&P) was not completed within 24 hours of admission. This
finding relates to which attribute of data quality?
A. Data precision
B. Data timeliness
C. Data granularity
D. Data consistency
Correct Answer: B
Explanation: Data timeliness refers to the requirement that data be recorded within a
specific timeframe that supports its use in patient care. The 24-hour H&P requirement is a
regulatory standard set by CMS and The Joint Commission to ensure clinical information is
available for treatment planning. Failure to meet this window is a deficiency in timeliness,
not precision or granularity.
3. A patient was admitted on June 1st and discharged on June 5th. Using the standard
formula for calculating the length of stay (LOS), how many days was the patient in the
hospital?
A. 5 days
B. 6 days
C. 3 days
D. 4 days
,Correct Answer: D
Explanation: The length of stay is calculated by subtracting the date of admission from the
date of discharge. In this case, June 5 minus June 1 equals 4 days. The day of discharge is
generally not counted in the LOS calculation to avoid over-reporting utilization.
4. A healthcare facility is implementing a new Electronic Health Record (EHR). The project
manager wants to ensure the data in the new system is accurately transferred from the old
system. Which process should be performed?
A. Data mining
B. Data scrubbing
C. Data mapping
D. Data warehousing
Correct Answer: C
Explanation: Data mapping is the process of creating a crosswalk between two systems to
ensure that data elements in the source system match the requirements of the target
system. This is critical during EHR transitions to maintain data integrity and consistency
across different platforms. Data scrubbing, while related, refers more specifically to
correcting or removing inaccurate records within a single database.
, 5. During a review of the Charge Description Master (CDM), an HIM professional finds that
several old CPT codes are still being used. What is the primary risk associated with this
finding?
A. Breach of patient confidentiality
B. Increased software maintenance costs
C. Claim denials and revenue loss
D. Inaccurate patient demographics
Correct Answer: C
Explanation: The CDM must be updated annually to reflect changes in CPT and HCPCS
codes to ensure accurate billing. Using outdated codes leads to immediate claim rejections
by payers, delaying reimbursement and impacting the facility’s cash flow. Maintaining the
CDM is a collaborative effort between HIM, finance, and clinical departments to support the
revenue cycle.
6. A researcher requests access to the hospital’s cancer registry for a study on lung cancer
outcomes. The registry contains names, addresses, and social security numbers. According to
the HIPAA Privacy Rule, what must be done before the researcher can access the data?
A. The researcher must pay a fee for the data.
B. The data must be de-identified or the researcher must obtain an IRB waiver.
C. The researcher must sign a business associate agreement.
D. The hospital must notify every patient in the registry.
Coding, Information Technology, Compliance and
Revenue Cycle
1. A coder reviews a patient record where the physician has documented ‘possible congestive
heart failure’ in the discharge summary. The patient was admitted for shortness of breath
and treated with diuretics. According to UHDDS guidelines for inpatient coding, how should
the coder proceed?
A. Query the physician to confirm the diagnosis before coding.
B. Code shortness of breath only as the principal diagnosis.
C. Code congestive heart failure as if it were established.
D. Assign a code for an unspecified heart condition.
Correct Answer: C
Explanation: According to the UHDDS, if the diagnosis documented at the time of
discharge is qualified as ‘possible,’ ‘probable,’ or ‘suspected,’ it is coded as if it were
established for inpatient records. This principle ensures that the resources consumed in
treating the suspected condition are captured. A common trap is assuming a query is
always required, but for inpatient settings, these qualifiers are acceptable for final coding if
they are documented at discharge.
,2. An HIM professional is conducting a qualitative analysis of a medical record and notices
that the history and physical (H&P) was not completed within 24 hours of admission. This
finding relates to which attribute of data quality?
A. Data precision
B. Data timeliness
C. Data granularity
D. Data consistency
Correct Answer: B
Explanation: Data timeliness refers to the requirement that data be recorded within a
specific timeframe that supports its use in patient care. The 24-hour H&P requirement is a
regulatory standard set by CMS and The Joint Commission to ensure clinical information is
available for treatment planning. Failure to meet this window is a deficiency in timeliness,
not precision or granularity.
3. A patient was admitted on June 1st and discharged on June 5th. Using the standard
formula for calculating the length of stay (LOS), how many days was the patient in the
hospital?
A. 5 days
B. 6 days
C. 3 days
D. 4 days
,Correct Answer: D
Explanation: The length of stay is calculated by subtracting the date of admission from the
date of discharge. In this case, June 5 minus June 1 equals 4 days. The day of discharge is
generally not counted in the LOS calculation to avoid over-reporting utilization.
4. A healthcare facility is implementing a new Electronic Health Record (EHR). The project
manager wants to ensure the data in the new system is accurately transferred from the old
system. Which process should be performed?
A. Data mining
B. Data scrubbing
C. Data mapping
D. Data warehousing
Correct Answer: C
Explanation: Data mapping is the process of creating a crosswalk between two systems to
ensure that data elements in the source system match the requirements of the target
system. This is critical during EHR transitions to maintain data integrity and consistency
across different platforms. Data scrubbing, while related, refers more specifically to
correcting or removing inaccurate records within a single database.
, 5. During a review of the Charge Description Master (CDM), an HIM professional finds that
several old CPT codes are still being used. What is the primary risk associated with this
finding?
A. Breach of patient confidentiality
B. Increased software maintenance costs
C. Claim denials and revenue loss
D. Inaccurate patient demographics
Correct Answer: C
Explanation: The CDM must be updated annually to reflect changes in CPT and HCPCS
codes to ensure accurate billing. Using outdated codes leads to immediate claim rejections
by payers, delaying reimbursement and impacting the facility’s cash flow. Maintaining the
CDM is a collaborative effort between HIM, finance, and clinical departments to support the
revenue cycle.
6. A researcher requests access to the hospital’s cancer registry for a study on lung cancer
outcomes. The registry contains names, addresses, and social security numbers. According to
the HIPAA Privacy Rule, what must be done before the researcher can access the data?
A. The researcher must pay a fee for the data.
B. The data must be de-identified or the researcher must obtain an IRB waiver.
C. The researcher must sign a business associate agreement.
D. The hospital must notify every patient in the registry.
