RHIT EXAM PREP PRACTICE QUESTIONS (Coding) LATEST EDITION 2025 GUARANTEED GRADE A+

D) Acute cholecystitis Select the correct term 1 (123) According to the UHDDS, which of the following is the definition of "other diagnoses"? A) Is recorded in the patient record B) Is documented by the attending physician and cannot be documented by any other provider C) Is considered all conditions that coexist at the time of admission or develop subsequently that affect the treatment received and/or the length of stay D) Is documented by at least wo physicians and/or the nursing staff 2 (115) The patient was admitted with nausea, vomiting and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting and abdominal pain. Which of the following would be the correct coding and sequencing for this case? A) Acute cholecystitis, nausea, vomiting, abdominal pain B) Abdominal pain, vomiting, nausea, acute cholecystitis C) Nausea, vomiting, abdominal pain D) Acute cholecystitis 3 (142) Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals? A) Current Procedural Terminology B) 'Diagnostic and Statistical Manual of Mental Disorders', Fourth Revision C) Healthcare Common Procedure Coding System D) 'International Classification of Diseases', Ninth Revision, Clinical Modification 4 (121) A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding sequencing for the current hospital stay? A) Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion B) Mental confusion; history of carcinoma of the prostate; admission for chemotherapy C) Metastatic carcinoma of the brain; history of carcinoma of the prostate D) Carcinoma of the prostate; metastatic carcinoma to the brain Terms in this set (87) (113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described in the pathology report B) Dimension of the specimen submitted as described in the pathology report C) Width times the length of the lesion as described in the operative report D) Diameter of the lesion as well as the margins excised as described in the operative report D) Diameter of the lesion as well as the margins excised as described in the operative report (114) According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? A) Complex B) Intermediate C) Not specified D) Simple A) Complex (115) The patient was admitted with nausea, vomiting and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting and abdominal pain. Which of the following would be the correct coding and sequencing for this case? A) Acute cholecystitis, nausea, vomiting, abdominal pain B) Abdominal pain, vomiting, nausea, acute cholecystitis C) Nausea, vomiting, abdominal pain D) Acute cholecystitis D) Acute cholecystitis (116) A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? A) Miscarriage B) Complications of spontaneous abortion with sepsis C) Sepsis D) Spontaneous abortion with sepsis A) Miscarriage (117) An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis". How should this case be coded? A) Code sepsis as the principal diagnosis with urinary tract infection due to E.coli as secondary diagnosis B) Code urinary tract infection with sepsis as the principal diagnosis C) Query the physician to ask if the patient has septicemia because of the symptomatology D) Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis C) Query the physician to ask if the patient has septicemia because of the symptomatology (118) The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: A) Unbundling B) Upcoding C) Medically unnecessary services D) Billing for services not provided B) Upcoding (119) A 65 year-old patient with a history of lung cancer is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department as well as a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? A) Ataxia B) Fractured arm C) Metastatic carcinoma of the brain D) Carcinoma of the lung C) Metastatic carcinoma of the brain (120) A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? A) Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina B) Infectious gastroenteritis; chronic obstructive pulmonary disease; angina C) Gastroenteritis; abdominal pain; angina D) Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina B) Infectious gastroenteritis; chronic obstructive pulmonary disease; angina (121) A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding sequencing for the current hospital stay? A) Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion B) Mental confusion; history of carcinoma of the prostate; admission for chemotherapy C) Metastatic carcinoma of the brain; history of carcinoma of the prostate D) Carcinoma of the prostate; metastatic carcinoma to the brain C) Metastatic carcinoma of the brain; history of carcinoma of the prostate (122) A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: A) Either the pancreatitis or noncalculus cholecystitis sequenced as the principal diagnosis B) Pancreatitis; noncalculus cholecystitis; abdominal pain C) Noncalculus cholecystitis; pancreatitis; abdominal pain D) Abdominal pain; pancreatitis; noncalculus cholecystitis A) Either the pancreatitis or noncalculus cholecystitis sequenced as the principal diagnosis (123) According to the UHDDS, which of the following is the definition of "other diagnoses"? A) Is recorded in the patient record B) Is documented by the attending physician and cannot be documented by any other provider C) Is considered all conditions that coexist at the time of admission or develop subsequently that affect the treatment received and/or the length of stay D) Is documented by at least wo physicians and/or the nursing staff C) Is considered all conditions that coexist at the time of admission or develop subsequently that affect the treatment received and/or the length of stay (124) A seven year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? A) Acute bronchitis B) Acute bronchitis with chronic obstructive pulmonary disease C) Asthma with status asthmaticus D) Chronic obstructive asthma C) Asthma with status asthmaticus (125) A coder might find which of the following on a patient's problem list if the medication list contain the drug Procardia? A) Esophagitis B) Hypertension C) Schizophrenia D) AIDS B) Hypertension (126) A physician orders a chest x-ray for an office patient who presents with fever, productive cough, and shortness of breath. The physician indicated in the progress notes: "Rule out pneumonia." What should the coder report for the visit when the results have not yet been received? A) Pneumonia B) Fever, cough, shortness of breath C) Cough, shortness of breath D) Pneumonia, cough, shortness of breath, fever B) Fever, cough, shortness of breath (128) Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products and services? A) Current Procedural Terminology B) Healthcare Common Procedure Coding System C) 'International Classification of Diseases', Ninth Revision, Clinical Modification D) 'International Classification of Diseases for Oncology', Third Edition C) Healthcare Common Procedure Coding System (129) Which of the following provides a detailed classification system for coding the histology, topography, and behavior of neoplasms? A) Current Procedural Terminology B) Healthcare Common Procedure Coding System C) 'International Classification of Diseases for Oncology', Third Edition D) Systematized Nomenclature of Medicine Clinical Terminology C) 'International Classification of Diseases for Oncology', Third Edition (131) Which of the following provides the most comprehensive, controlled vocabulary for coding the content of a patient record? A) CPT B) HCPCS C) ICD-10-CM D) SNOMED-CT D) SNOMED-CT (133) Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2? A) Current Procedural Terminology (CPT) B) 'International Classification of Diseases', Tenth Revision, Clinical Modification (ICD-10-CM and ICD-10-PCS) C) 'International Classification of Diseases', Tenth Revision (ICD-10) D) 'International Classification of Diseases', Tenth Revision, Clinical Modification (ICD-10-CM) D) 'International Classification of Diseases', Tenth Revision, Clinical Modification (ICD-10-CM) (134) Which organization originally published ICD-10? A) American Medical Association B) Centers for Disease Control C) United States federal government D) World Health Organization D) World Health Organization (135) When reporting an encounter for a patient who is HIV positive but has never had any symptoms, the following code is assigned: A) B20, Human immunodeficiency virus [HIV] disease B) Z21, Asymptomatic HIV infection status C) Z21, Asymptomatic human immunodeficiency virus [HIV] infection status D) Z20.6, Contact with and (suspected) exposure to human immunodeficiency virus [HIV] B) Z21, Asymptomatic HIV infection status (136) Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient but another physician performed the surgical procedure. A) -22, Increased procedural services B) -54, Surgical care only C) -32, Mandated service D) -55, Postoperative management only D) -55, Postoperative management only (137) Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket A) 33223, Relocation of skin pocket for cardioverter-defibrillator B) 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) C) 33212, Insertion of a pacemaker pulse generator only; with existing single lead D) 33222, Relocation of skin pocket for pacemaker D) 33222, Relocation of skin pocket for pacemaker (138) The ICD-10-CM utilizes a placeholder character at certain codes to allow for future expansion of the classification system. What letter is used to represent this placeholder character? A) A B) G C) U D) X D) X (139) Assign the correct CPT code for the following: A 63 year-old female had a temporal artery biopsy completed in the outpatient surgical center. A) 32405, Biopsy, lung or mediastinum, percutaneous needle B) 37609, Ligation or biopsy, temporal artery C) 20206, Biopsy, muscle percutaneous needle D) 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needles aspiration biopsy(s), trachea, mainstem and/or lobar bronchus(i) B) Ligation or biopsy, temporal artery (140) In ICD-10-PCS, the root operation defined as taking or letting out fluids and/or gases from a body part is: A) Control B) Drainage C) Excision D) Release B) Drainage (141) A physician query may not be appropriate in which of the following instances? A) Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae B) Discharge summary indicates chronic renal failure but the progress notes documents acute renal failure throughout the stay C) Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis D) Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI C) Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis (142) Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals? A) Current Procedural Terminology B) 'Diagnostic and Statistical Manual of Mental Disorders', Fourth Revision C) Healthcare Common Procedure Coding System D) 'International Classification of Diseases', Ninth Revision, Clinical Modification A) Current Procedural Terminology (143) Which of the following conditions are included on the hospital-acquired conditions provision list? A) Pressure ulcers, Staphylococcus infections, gunshot wounds B) Staphylococcus infections, air embolism, physical and substance abuse C) Catheter-associated urinary tract infections, gunshot wounds D) Pressure ulcers, catheter-associated urinary tract infections, falls and fractures D) Pressure ulcers, catheter-associated urinary tract infections, falls and fractures (144) The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? A) Have coders continue to query the attending physician for this documentation B) Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines C) Do nothing because coding compliance guidelines do not allow any action D) Place all offending physicians on suspension if the documentation issues continue B) Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines (145) Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures? A) Reliability B) Validity C) Completeness D) Timeliness B) Validity (146) A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a comorbid condition? A) Acute appendicitis B) Appendectomy C) Diabetes D) Wound infection C) Diabetes (150) Which of the following is the condition established after study to be the reason for hospitalization? A) Principal procedure B) Complication C) Comorbidity D) Principal diagnosis D) Principal diagnosis (151) Which of the following is a prospective payment system implemented for inpatient services? A) APC B) MS-DRG C) OPPS D) RBRVS B) MS-DRG (152) In the inpatient prospective payment system, the calculation of the DRG begins with the: A) Principal diagnosis B) Primary diagnosis C) Secondary diagnosis D) Surgical procedure A) Principal diagnosis (153) Diagnosis-related groups are organized into: A) Case-mix classifications B) Geographic practice cost indices C) Major diagnostic categories D) Resource-based relative values C) Major diagnostic categories (154) NCCI edits prevent improper payments in which of the following cases? A) Medical necessity has not been justified by a diagnosis B) The account is potentially upcoded C) The claim contains any of a variety of errors D) Incorrect code combinations are on the claim D) Incorrect code combinations are on the claim (155) Medicare inpatient reimbursement levels are based on: A) CPT codes reported during the encounter B) MS-DRG calculated for the encounter C) Charges accumulated during the episode of care D) Usual and customary charges reported during the encounter B) MS-DRG calculated for the encounter (156) Coding and billing documentation must be based on the: A) Wishes of the patient B) Highest available reimbursement amount C) Most efficient utilization of resources D) Provider's documentation D) Provider's documentation (157) Unbundling refers to: A) Use of a comprehensive code to appropriately maximize reimbursement B) Use of multiple procedure codes when a comprehensive code is available C) Combined billing for pre- and postsurgery physician services D) Using the incorrect DRG code A) Use of a comprehensive code to appropriately maximize reimbursement (158) MS-DRGs may be split into a maximum of _______ payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC, or no CC A) Two B) Three C) Four D) Five B) Three (159) The purpose of the present on admission indicator is to: A) Differentiate between conditions present on admission and conditions that develop during an inpatient admission B) Track principal diagnosis C) Distinguish between principal and primary diagnosis D) Determine principal diagnosis A) Differentiate between conditions present on admission and conditions that develop during an inpatient admission (160) The present on admission indicator is a requirement for: A) Inpatient Medicare claims submitted by hospitals B) Inpatient Medicare and Medicaid claims submitted by hospitals C) Medicare claims submitted by all entities D) Inpatient skilled nursing facility Medicare claims A) Inpatient Medicare claims submitted by hospitals (161) A coding audit shows an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? A) Require all coders to implement this practice B) Report the practice to the OIG C) Counsel the coder and stop the practice immediately D) Put the coder on unpaid leave of absence C) Counsel the coder and stop the practice immediately (162) The National Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for: A) Part A Medicare claims B) Part B Medicare claims C) Medicaid claims D) Medicare and Medicaid claims B) Part B Medicare claims (163) The function of the NCCI editor is to: A) Report poor performing physicians B) Identify procedures and services that cannot be billed together on the same day of service for a patient C) Identify poor performing coders D) Identify problems in the national coding system B) Identify procedures and services that cannot be billed together on the same day of service for a patient (164) NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for: A) Services that cannot reasonably be billed together B) Services that are components of a more comprehensive procedure C) Unnecessary procedures D) Comprehensive procedures A) Services that cannot reasonably be billed together (165) The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of: A) Speed B) Data quality and integrity C) Accuracy D) Effective relationships with physicians and facility personnel B) Data quality and integrity (166) Quality standards for coding accuracy should be: A) At least 90 percent B) At least 95 percent C) As close to 100 percent as possible D) No specific standards are possible C) As close to 100 percent as possible (167) The acute-care hospital discharges an average of 55 patients per day. The HIM department is open during normal business hours only. The volume productivity standard is six records per hour when coding 4.5 hours per day. Assuming that the standards are met, how many FTE coders does the facility need to have on staff in order to ensure that there is no backlog? A) 2.85 B) 5 C) 14.26 D) 27 A) 2.85 (168) A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician? A) Insomnia B) Hypertension C) Mental or behavioral problems D) Rheumatoid arthritis C) Mental or behavior problems (169) Mary Patient presented to the emergency department with chest pains and shortness of breath. She was treated for congestive heart failure and returned home. Two days later, her symptoms had worsened. She presented again to the emergency department and was admitted to the hospital for inpatient treatment of congestive heart failure. The hospital will bill Medicare for: A) Two emergency department visits as an outpatient service and the inpatient visit under MS-DRGs B) One inpatient visit under MS-DRGs C) One emergency department visit as an outpatient service and one inpatient visit under MS-DRGs D) Two emergency department visits as an outpatient service and the inpatient visit at a reduced rate under MS-DRGs CONTINUED..