RHIT Exam Questions, RHIT Exam Terminology
Inpatient occupancy rate: - ANSWER:(Service days x 100) / (number of beds x service days) = percentage
rate %
Under HIPAA, which of the following is not named as a covered entity? - ANSWER:Outsourced
transcription company; they would be business associates of a covered entity
A standard of performance or best practice for a particular process or outcome is called a(n)_____ -
ANSWER:Benchmark
The breach notification requirement applies to_____ - ANSWER:Unsecured PHI only
Which of the following would be the best course of action to take to ensure continuous availability of
electronic data? - ANSWER:Use redundant servers.
_________means that as data is entered and processed by one server, that data is also entered and
processed simultaneously by a second server. Should the primary server crash, the system should be
designed to "fail over" to the second server. - ANSWER:server redundancy
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at
the correct level of detail. This indicates a problem with ________ - ANSWER:Data Granularity
What is the first step an organization should take when developing a data dictionary? - ANSWER:Design a
plan
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando
Hospital. Jeremy's medical information is___ - ANSWER:Not protected by the Privacy Rule because it is
part of a personnel record
A patient requests copies of her medical records in an electronic format. The hospital does not maintain
all of the designated records in an electronic format. How should the hospital respond? -
ANSWER:Provide the records in paper format only
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? - ANSWER:31.5
To use a data element for aggregation and reporting, that data element must be: - ANSWER:Abstracted
or indexed
Which of the following is a function of the outpatient code editor? - ANSWER:Identify unbundling of
codes
The first step in an inpatient record review is to verify correct assignment of the: - ANSWER:Principal
diagnosis
The goal of coding compliance programs is to prevent____ - ANSWER:Accusations of fraud and abuse
The leaders of a healthcare organization are expected to select an organization-wide performance
improvement approach and to clearly define how all levels of the organization will monitor and address
,improvement issues. The Joint Commission requires ongoing data collection that might require
improvement for which of the following areas? - ANSWER:Operative and other invasive procedures,
medication management, and blood and blood product use
The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing
schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day.
The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records
per hour. Given these standards, how many filing hours will be required daily to retrieve and file records
for each clinic day? - ANSWER:22.5 hours per day
The HIM department is developing a system to track coding productivity. The director wants the system
to track the productivity of each coder by productive hours worked per day, health record ID, type of
records coded, and to provide weekly productivity reports and analyses. Which of the following tools
would be best to use for this purpose? - ANSWER:Database management system
Which of the following is the approved method for implementing an organization's formal position? -
ANSWER:Policy and procedure
Which of the following elements of coding quality represents the degree to which codes accurately
reflect the patient's diagnoses and procedure - ANSWER:Validity
Which of the following is true about a primary key in a database table? - ANSWER:Uniquely identifies
each row in a table
Covered entities must do which of the following to comply with HIPAA security provisions? -
ANSWER:Establish a contingency plan
Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to
the physician office visits because she often forgets to tell the physician vital information. Under the
Privacy Rule, the release of her mother's PHI to Jennifer is: - ANSWER:Allowed when the information is
directly relevant to Jennifer's involvement in her mother's care or treatment
Which of the following procedures or services could not be assigned a code with cpt? -
ANSWER:Crutches
Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical
Center for further evaluation and treatment. He was discharged to home after three days. Community
Hospital will receive from Medicare: - ANSWER:A per diem rate for the two-day stay, and Big Medical
Center will receive the full DRG payment
A Clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid:
- ANSWER:Assumption coding
Which of the following is an example of how an internal user utilizes secondary data? -
ANSWER:Benchmarking with other facilities
The breach notification requirement applies to____ - ANSWER:Unsecured PHI only
The present on admission indicator is a requirement for____ - ANSWER:Inpatient Medicare claims
submitted by hospitals
,What is the term that means evaluating the appropriateness of the setting for the healthcare service and
the level of service? - ANSWER:Utilization review
Which of the following is one of the five best practices for management of financial measures in the CDI
program? - ANSWER:Track and report on CC capture rates across the organization and by service
CC/MCC Means - ANSWER:Complication or Comorbidity/ Major complication or Comorbidity
Which of the following could be a focus of a coding quality review program? - ANSWER:Coding
completed by new coders
Which of the following provide the objective and scope for the HIPAA Security Rule as a whole? -
ANSWER:General Rules
A comprehensive retrospective review should be conducted at least once a year of what aspect of the
clinical documentation improvement program? - ANSWER:All query opportunities
RACs conduct three types of audits: - ANSWER:automated reviews, semi-automated reviews, and
complex reviews.
Using data mining, an RAC makes a claim determination at the system-level without a human review of
the health record. This type of review is called: - ANSWER:Automated review
Which of the following is a principle of contemporary performance improvement? -
ANSWER:Performance improvement relies on the collection and analysis of data to increase knowledge.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report? - ANSWER:Medication administration record and clinical laboratory reports
Which of the following is an individual user of the health record? - ANSWER:Clinical professionals who
provide direct patient care, Billers in the healthcare facility's business office, Patient care managers;
those who depend on the health record in order to complete their job
The Master Patient Index is used____ - ANSWER:By the HIM department to look up patient
demographics, dates of care, the patient's health record number, and other information
A bed count, also called an inpatient bed count, is ____Temporary beds are not included in the bed
count for percentage of occupancy - ANSWER:the number of available hospital inpatient beds, both
occupied and vacant, on any given day.
An example of data mapping is____ - ANSWER:mapping two different coding systems to show equivalent
codes allows for data initially captured for one purpose to be translated and used for another purpose.
______ are not included in the bed count for percentage of occupancy - ANSWER:Temporary beds
The consultation report is based on the consulting______ - ANSWER:Physician's examination of the
patient and a review of his or her health record.
, A tornado touched down in the community and multiple patients were brought to the hospital. The HIM
director has asked all department personnel to report to the emergency staging area to help with record
management. The HIM director is performing which function of management? - ANSWER:Leading
The Uniform Ambulatory Care Data Set (UACDS) data characteristics include: - ANSWER:Patient-specific
items for outpatient care.
Leading is defined as - ANSWER:the function in which people are directed and motivated to achieve the
goals of the healthcare organization.
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the
following data sets should the clinic consult to ensure that all the federally recommended data elements
for Medicare and Medicaid outpatients are collected by the system? - ANSWER:Uniform Ambulatory
Care Data Set - UACDS
What should be done when the HIM department's error rate is too high or its accuracy rate is too low
based on policy? - ANSWER:Corrective action should be taken to meet the department standards
How do accreditation organizations (Joint Commission) use the health record? - ANSWER:To determine
whether standards of care are being met.
When the Medicare Recovery Audit Contractor has determined that incorrect payment has been made
to an organization, which document is sent to the provider notifying them of this determination? -
ANSWER:Demand letter
To comply with the Joint Commission standards, the HIM director wants to be sure that history and
physical examinations are documented in the patient's health record no later than 24 hours after
admission. Which of the following would be the best way to ensure the completeness of the health
record? - ANSWER:Review each patient's health record concurrently to make sure that history and
physicals are present.
The evaluation of coders is recommended at least quarterly for the purpose of measurement and
assurance of: - ANSWER:Data quality and integrity
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs? - ANSWER:Medicare Conditions of Participation or Conditions of
Coverage
After implementing a new EHR, the HIM department is noticing that documents are occasionally found
in the wrong health record or are mislabeled. Which of the following would be the best approach to
manage these errors in the EHR? - ANSWER:Establish an error-management team to receive notice of
these instances and correct them
The Medicare Conditions of Participation are administered by____ - ANSWER:the federal government
Centers for Medicare and Medicaid Services (CMS)
One way for a hospital to demonstrate compliance with OIG guidelines is to: - ANSWER:Develop,
implement, and monitor written policies and procedures
Inpatient occupancy rate: - ANSWER:(Service days x 100) / (number of beds x service days) = percentage
rate %
Under HIPAA, which of the following is not named as a covered entity? - ANSWER:Outsourced
transcription company; they would be business associates of a covered entity
A standard of performance or best practice for a particular process or outcome is called a(n)_____ -
ANSWER:Benchmark
The breach notification requirement applies to_____ - ANSWER:Unsecured PHI only
Which of the following would be the best course of action to take to ensure continuous availability of
electronic data? - ANSWER:Use redundant servers.
_________means that as data is entered and processed by one server, that data is also entered and
processed simultaneously by a second server. Should the primary server crash, the system should be
designed to "fail over" to the second server. - ANSWER:server redundancy
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at
the correct level of detail. This indicates a problem with ________ - ANSWER:Data Granularity
What is the first step an organization should take when developing a data dictionary? - ANSWER:Design a
plan
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando
Hospital. Jeremy's medical information is___ - ANSWER:Not protected by the Privacy Rule because it is
part of a personnel record
A patient requests copies of her medical records in an electronic format. The hospital does not maintain
all of the designated records in an electronic format. How should the hospital respond? -
ANSWER:Provide the records in paper format only
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? - ANSWER:31.5
To use a data element for aggregation and reporting, that data element must be: - ANSWER:Abstracted
or indexed
Which of the following is a function of the outpatient code editor? - ANSWER:Identify unbundling of
codes
The first step in an inpatient record review is to verify correct assignment of the: - ANSWER:Principal
diagnosis
The goal of coding compliance programs is to prevent____ - ANSWER:Accusations of fraud and abuse
The leaders of a healthcare organization are expected to select an organization-wide performance
improvement approach and to clearly define how all levels of the organization will monitor and address
,improvement issues. The Joint Commission requires ongoing data collection that might require
improvement for which of the following areas? - ANSWER:Operative and other invasive procedures,
medication management, and blood and blood product use
The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing
schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day.
The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records
per hour. Given these standards, how many filing hours will be required daily to retrieve and file records
for each clinic day? - ANSWER:22.5 hours per day
The HIM department is developing a system to track coding productivity. The director wants the system
to track the productivity of each coder by productive hours worked per day, health record ID, type of
records coded, and to provide weekly productivity reports and analyses. Which of the following tools
would be best to use for this purpose? - ANSWER:Database management system
Which of the following is the approved method for implementing an organization's formal position? -
ANSWER:Policy and procedure
Which of the following elements of coding quality represents the degree to which codes accurately
reflect the patient's diagnoses and procedure - ANSWER:Validity
Which of the following is true about a primary key in a database table? - ANSWER:Uniquely identifies
each row in a table
Covered entities must do which of the following to comply with HIPAA security provisions? -
ANSWER:Establish a contingency plan
Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to
the physician office visits because she often forgets to tell the physician vital information. Under the
Privacy Rule, the release of her mother's PHI to Jennifer is: - ANSWER:Allowed when the information is
directly relevant to Jennifer's involvement in her mother's care or treatment
Which of the following procedures or services could not be assigned a code with cpt? -
ANSWER:Crutches
Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical
Center for further evaluation and treatment. He was discharged to home after three days. Community
Hospital will receive from Medicare: - ANSWER:A per diem rate for the two-day stay, and Big Medical
Center will receive the full DRG payment
A Clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid:
- ANSWER:Assumption coding
Which of the following is an example of how an internal user utilizes secondary data? -
ANSWER:Benchmarking with other facilities
The breach notification requirement applies to____ - ANSWER:Unsecured PHI only
The present on admission indicator is a requirement for____ - ANSWER:Inpatient Medicare claims
submitted by hospitals
,What is the term that means evaluating the appropriateness of the setting for the healthcare service and
the level of service? - ANSWER:Utilization review
Which of the following is one of the five best practices for management of financial measures in the CDI
program? - ANSWER:Track and report on CC capture rates across the organization and by service
CC/MCC Means - ANSWER:Complication or Comorbidity/ Major complication or Comorbidity
Which of the following could be a focus of a coding quality review program? - ANSWER:Coding
completed by new coders
Which of the following provide the objective and scope for the HIPAA Security Rule as a whole? -
ANSWER:General Rules
A comprehensive retrospective review should be conducted at least once a year of what aspect of the
clinical documentation improvement program? - ANSWER:All query opportunities
RACs conduct three types of audits: - ANSWER:automated reviews, semi-automated reviews, and
complex reviews.
Using data mining, an RAC makes a claim determination at the system-level without a human review of
the health record. This type of review is called: - ANSWER:Automated review
Which of the following is a principle of contemporary performance improvement? -
ANSWER:Performance improvement relies on the collection and analysis of data to increase knowledge.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report? - ANSWER:Medication administration record and clinical laboratory reports
Which of the following is an individual user of the health record? - ANSWER:Clinical professionals who
provide direct patient care, Billers in the healthcare facility's business office, Patient care managers;
those who depend on the health record in order to complete their job
The Master Patient Index is used____ - ANSWER:By the HIM department to look up patient
demographics, dates of care, the patient's health record number, and other information
A bed count, also called an inpatient bed count, is ____Temporary beds are not included in the bed
count for percentage of occupancy - ANSWER:the number of available hospital inpatient beds, both
occupied and vacant, on any given day.
An example of data mapping is____ - ANSWER:mapping two different coding systems to show equivalent
codes allows for data initially captured for one purpose to be translated and used for another purpose.
______ are not included in the bed count for percentage of occupancy - ANSWER:Temporary beds
The consultation report is based on the consulting______ - ANSWER:Physician's examination of the
patient and a review of his or her health record.
, A tornado touched down in the community and multiple patients were brought to the hospital. The HIM
director has asked all department personnel to report to the emergency staging area to help with record
management. The HIM director is performing which function of management? - ANSWER:Leading
The Uniform Ambulatory Care Data Set (UACDS) data characteristics include: - ANSWER:Patient-specific
items for outpatient care.
Leading is defined as - ANSWER:the function in which people are directed and motivated to achieve the
goals of the healthcare organization.
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the
following data sets should the clinic consult to ensure that all the federally recommended data elements
for Medicare and Medicaid outpatients are collected by the system? - ANSWER:Uniform Ambulatory
Care Data Set - UACDS
What should be done when the HIM department's error rate is too high or its accuracy rate is too low
based on policy? - ANSWER:Corrective action should be taken to meet the department standards
How do accreditation organizations (Joint Commission) use the health record? - ANSWER:To determine
whether standards of care are being met.
When the Medicare Recovery Audit Contractor has determined that incorrect payment has been made
to an organization, which document is sent to the provider notifying them of this determination? -
ANSWER:Demand letter
To comply with the Joint Commission standards, the HIM director wants to be sure that history and
physical examinations are documented in the patient's health record no later than 24 hours after
admission. Which of the following would be the best way to ensure the completeness of the health
record? - ANSWER:Review each patient's health record concurrently to make sure that history and
physicals are present.
The evaluation of coders is recommended at least quarterly for the purpose of measurement and
assurance of: - ANSWER:Data quality and integrity
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs? - ANSWER:Medicare Conditions of Participation or Conditions of
Coverage
After implementing a new EHR, the HIM department is noticing that documents are occasionally found
in the wrong health record or are mislabeled. Which of the following would be the best approach to
manage these errors in the EHR? - ANSWER:Establish an error-management team to receive notice of
these instances and correct them
The Medicare Conditions of Participation are administered by____ - ANSWER:the federal government
Centers for Medicare and Medicaid Services (CMS)
One way for a hospital to demonstrate compliance with OIG guidelines is to: - ANSWER:Develop,
implement, and monitor written policies and procedures
