RHIT Practice EXAM 2025 150 QUESTIONS AND CORRECT
ANSWER
A health record technician has been asked to review the discharge patient abstracting module
of a proposed new electronic health record (EHR). Which of the following data sets would the
technician consult to ensure the system collects all federally required discharge data elements
for Medicare and Medicaid inpatients in an acute-care hospital?
CARF
DEEDS
UACDS
UHDDS - answer>>>d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific
items on every inpatient.
As part of your job responsibilities, you are responsible for reviewing audit trails of access to
patient information. The following are all types of activities that you would monitor except:
Every access to every data element or document type
Whether the person viewed, created, updated, or deleted the information
Physical location on the network where the access occurred
Whether the patient setup an account in the patient portal - answer>>>d. Whether
the patient setup an account in the patient portal
The HIPAA Security Rule requires that access to electronic PHI in information systems is
monitored. Included in the same standard is the requirement that covered entities examine the
activity using access audit logs. Often they record: time stamps that record access and use of
the data elements and documents; what was viewed, created, updated, or deleted; the user's
identification; the owner of the record; and the physical location on the network where the
access occurred. Creation of an account through the patient portal by the patient is appropriate
use.
Which of the following is the first step in analyzing data?
,a. Knowing your objectives or purpose of the data analysis
b. Starting with basic types of data analysis and work up to more sophisticated analysis
c. Utilizing a statistician to analyze the data
d. Presenting your findings to administration - answer>>>a. Knowing your objectives or purpose
of the data analysis
The first step in analyzing data is to know your objective or the purpose of the data analysis.
Sometimes data do not follow a normal distribution and are pulled toward the tails of the
curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is
sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus
making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it
is called a __________.
a. Negatively skewed distribution
b. Positively skewed distribution
c. Bimodal distribution
d. Normal distribution - answer>>>b. Positively skewed distribution
When the tail is pulled toward the right side, it is called a positively skewed distribution; when
the tail is pulled toward the left side of the curve it is called a negatively skewed distribution.
Recently, a local professional athlete was admitted to your facility for a procedure. During this
patient's hospital stay, access logs may need to be checked daily in order to determine:
a. Whether access by employees is appropriate
b. If the patient is satisfied with their stay
c. If it is necessary to order prescriptions for the patient
d. Whether the care to the patient meets quality standards - answer>>>a. Whether access by
employees is appropriate
,In order to maintain patient privacy certain audits may need to be completed daily. If a high
profile patient is currently in a facility, for example, access logs may need to be checked daily to
determine whether all access to this patient's information by workforce is appropriate.
The accounts not selected for the billing report is a daily report used to track accounts that are:
a. Awaiting payment in accounts receivable
b. Paid at different rates
c. In bill hold or in error and awaiting billing
d. Pulled for quality review - answer>>>c. In bill hold or in error and awaiting billing
The accounts not selected for billing report is a daily report used to track the many reasons that
accounts may not be ready for billing. This report is also called the discharged not final billed
(DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and
reported on this daily tracking list. Some accounts are held because the patient has not signed
the consents and authorizations required by the insurer. Still others are not billed because the
primary and secondary insurance benefits have not been confirmed .
Which of the following is a function of the outpatient code editor?
a. Validate the patient's age on a claim
b. Validate the patient's encounter number
c. Identify unbundling of codes
d. Identify cases that don't meet medical necessity - answer>>>c. Identify unbundling of codes
The latest version of the Medicare integrated outpatient code editor (OCE) should be installed
to review claims prior to releasing billed data to the Medicare program. OCE software contains
the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT).
The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to
control improper coding leading to inappropriate payment and unbundling on the Part B claims.
They also identify component codes that were used instead of the appropriate comprehensive
code, as well as other types of coding errors.
, A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary
liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following
should be sequenced as the principal diagnosis?
a. Dehydration
b. Chemotherapy
c. Liver carcinoma
d. Complication of chemotherapy - answer>>>a. Dehydration
When the admission or encounter is for management of dehydration due to the malignancy
and only the dehydration is being treated, the dehydration is sequenced first, followed by the
code(s) for the malignancy.
The first step in an inpatient record review is to verify correct assignment of the:
a. Record sample
b. Coding procedures
c. Principal diagnosis
d. MS-DRG - answer>>>c. Principal diagnosis
To begin the review, the coding supervisor checks the inpatient health record to ensure that the
diagnosis billed as principal meets the official Uniform Hospital Discharge Data Set (UHDDS)
definition for principal diagnosis. The principal diagnosis must have been a principal reason for
admission, and the patient received treatment or evaluation during the stay. When several
diagnoses meet all of those requirements, any of them could be selected as the principal
diagnosis.
A patient was seen in the emergency department for chest pain. It was suspected that the
patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out
GERD." The correct ICD-10-CM diagnosis code is:
a. K21.9, Gastro-esophageal reflux disease without esophagitis
ANSWER
A health record technician has been asked to review the discharge patient abstracting module
of a proposed new electronic health record (EHR). Which of the following data sets would the
technician consult to ensure the system collects all federally required discharge data elements
for Medicare and Medicaid inpatients in an acute-care hospital?
CARF
DEEDS
UACDS
UHDDS - answer>>>d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific
items on every inpatient.
As part of your job responsibilities, you are responsible for reviewing audit trails of access to
patient information. The following are all types of activities that you would monitor except:
Every access to every data element or document type
Whether the person viewed, created, updated, or deleted the information
Physical location on the network where the access occurred
Whether the patient setup an account in the patient portal - answer>>>d. Whether
the patient setup an account in the patient portal
The HIPAA Security Rule requires that access to electronic PHI in information systems is
monitored. Included in the same standard is the requirement that covered entities examine the
activity using access audit logs. Often they record: time stamps that record access and use of
the data elements and documents; what was viewed, created, updated, or deleted; the user's
identification; the owner of the record; and the physical location on the network where the
access occurred. Creation of an account through the patient portal by the patient is appropriate
use.
Which of the following is the first step in analyzing data?
,a. Knowing your objectives or purpose of the data analysis
b. Starting with basic types of data analysis and work up to more sophisticated analysis
c. Utilizing a statistician to analyze the data
d. Presenting your findings to administration - answer>>>a. Knowing your objectives or purpose
of the data analysis
The first step in analyzing data is to know your objective or the purpose of the data analysis.
Sometimes data do not follow a normal distribution and are pulled toward the tails of the
curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is
sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus
making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it
is called a __________.
a. Negatively skewed distribution
b. Positively skewed distribution
c. Bimodal distribution
d. Normal distribution - answer>>>b. Positively skewed distribution
When the tail is pulled toward the right side, it is called a positively skewed distribution; when
the tail is pulled toward the left side of the curve it is called a negatively skewed distribution.
Recently, a local professional athlete was admitted to your facility for a procedure. During this
patient's hospital stay, access logs may need to be checked daily in order to determine:
a. Whether access by employees is appropriate
b. If the patient is satisfied with their stay
c. If it is necessary to order prescriptions for the patient
d. Whether the care to the patient meets quality standards - answer>>>a. Whether access by
employees is appropriate
,In order to maintain patient privacy certain audits may need to be completed daily. If a high
profile patient is currently in a facility, for example, access logs may need to be checked daily to
determine whether all access to this patient's information by workforce is appropriate.
The accounts not selected for the billing report is a daily report used to track accounts that are:
a. Awaiting payment in accounts receivable
b. Paid at different rates
c. In bill hold or in error and awaiting billing
d. Pulled for quality review - answer>>>c. In bill hold or in error and awaiting billing
The accounts not selected for billing report is a daily report used to track the many reasons that
accounts may not be ready for billing. This report is also called the discharged not final billed
(DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and
reported on this daily tracking list. Some accounts are held because the patient has not signed
the consents and authorizations required by the insurer. Still others are not billed because the
primary and secondary insurance benefits have not been confirmed .
Which of the following is a function of the outpatient code editor?
a. Validate the patient's age on a claim
b. Validate the patient's encounter number
c. Identify unbundling of codes
d. Identify cases that don't meet medical necessity - answer>>>c. Identify unbundling of codes
The latest version of the Medicare integrated outpatient code editor (OCE) should be installed
to review claims prior to releasing billed data to the Medicare program. OCE software contains
the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT).
The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to
control improper coding leading to inappropriate payment and unbundling on the Part B claims.
They also identify component codes that were used instead of the appropriate comprehensive
code, as well as other types of coding errors.
, A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary
liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following
should be sequenced as the principal diagnosis?
a. Dehydration
b. Chemotherapy
c. Liver carcinoma
d. Complication of chemotherapy - answer>>>a. Dehydration
When the admission or encounter is for management of dehydration due to the malignancy
and only the dehydration is being treated, the dehydration is sequenced first, followed by the
code(s) for the malignancy.
The first step in an inpatient record review is to verify correct assignment of the:
a. Record sample
b. Coding procedures
c. Principal diagnosis
d. MS-DRG - answer>>>c. Principal diagnosis
To begin the review, the coding supervisor checks the inpatient health record to ensure that the
diagnosis billed as principal meets the official Uniform Hospital Discharge Data Set (UHDDS)
definition for principal diagnosis. The principal diagnosis must have been a principal reason for
admission, and the patient received treatment or evaluation during the stay. When several
diagnoses meet all of those requirements, any of them could be selected as the principal
diagnosis.
A patient was seen in the emergency department for chest pain. It was suspected that the
patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out
GERD." The correct ICD-10-CM diagnosis code is:
a. K21.9, Gastro-esophageal reflux disease without esophagitis
