RHIT - Coding Exam Questions with Verified Solutions Latest Version 2025 Already Passed
Which of the following provides a means to record information about patients treated for substance
abuse and mental disorders?
a. Current Procedural Terminology
b. Diagnostic and Statistical Manual of Mental Disorders, 4th Revision
c. ICD-10-CM
d. Systematized Nomenclature of Medicine Clinical Terminology - Answers b. Diagnostic and Statistical
Manual of Mental Disorders, 4th Revision (DSM-IV-TR)
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 other data and to provide weekly productivity reports and analyses. Which of the
following tools would be best to use for this purpose?
a. Database management system
b. Paper log book
c. Spreadsheet
d. Word-process documents - Answers a. Database management system
Which of the following is a goal of ICD-10-PCS?
a. Assign diagnosis codes
b. Eliminate the need to communicate with physicians
c. Reduce inconsistency due to overlapping of terms
d. Assign diagnosis and procedure codes - Answers c. Reduce inconsistency due to overlapping of terms.
According to CMS, the design of ICD-10-PCS includes the following goals: to improve accuracy and
efficiency of coding, to reduce training effort, and to improve communication with physicians
Which of the following elements of coding quality represent the degree to which the codes capture all
the diagnosis and procedures documented in the patient's health record?
a. Completeness
b. Reliability
c. Timeliness
,d. Validity - Answers a. Completeness is the degree to which the code assignments captures all the
diagnoses and procedures documented in the health record.
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 - Answers c. Identify unbundling of codes. The latest
version of the Medicare integrated outpatient code editor (IOCE) should be installed to review claims
prior to releasing billed data to the Medicare program. IOCE software contains the NCCI edits for CPT.
A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver
cancer. IV fluids were administered to the patient. Which of the following should be sequenced as the
principal Dx?
a. Dehydration
b. Chemotherapy
c. Liver carcinoma
d. Complication of chemotherapy - Answers a. Dehydration. When the admission or encounter is for
management of dehydration due to malignancy and only the dehydration is being treated, the
dehydration is sequenced first, followed by the code(s) for malignancy.
The APC payment system is based on what coding system?
a. CPT/HCPCS codes
b. ICD-10-CM diagnosis and procedure codes
c. CPT and ICD-10-CM procedure codes
d. Only CPT codes - Answers a. CPT/HCPCS codes are how the calculation for payment of services are
based. Catergorization of outpatient services into APC groups are based on CPT/HCPCS codes.
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. DRG - Answers c Principal diagnosis. To begin the review, the coding supervisor checks the inpatient
record to ensure that the diagnosis billed as the principal Dx meets the UHDDS definition for principal
Dx.
A patient was seen in the ER for chest pain. It was suspected that the patient may have GERD. The final
diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is:
a. K21.9, Gastroesophageal reflux disease without esophagitis
b. R07.9, Chest pain, unspecified
c. R10.11, Right upper quadrant pain
d. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out - Answers b.
R07.9, Chest pain, unspecified. Because this is an outpatient visit, a diagnosis wiith "probable" or
"questionable" can not be coded as being definitive. Instead, code to highest level of certainty.
Coding accuracy is best determined by:
a. A predefined audit process
b. Medicare Conditions of Participation
c. Payer audits
d. Joint Commission Standards for Accreditation - Answers a. A predefined audit process. Coders should
be evaluated at least quarterly with appropriate training needs identified, facilitated, and reassessed
over time. Only through this continuous process of evaluation can quality and integrity be measured and
ensured.
Complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port;
replacement performed through original access site (45yo patient). Which of the follow CPT codes is
most appropriate?
36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump,
central or peripheral insertion site
36580 Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access
36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with
subcutaneous port, through the same venous access
36597 Repositioning of prevously placed central venous catheter under fluoroscopic guidance
a. 36578
b. 36580
, c. 36582, 36597
d. 36582 - Answers d. 36582 Complete replacement of entire device by the same venous access site;
tunneled catheter inserted within the same venous access point
A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment?
49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of
specimen(s) by brushing or washing (separate procedure)
58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvis viscera, or
peritoneal surface by any method
58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671 Laparoscopy, surgical; with occlusions of oviducts by device (eg. band, clip, or Falope ring)
a. 49320, 58662
b. 58670
c. 58671
d. 49320 - Answers b. 58670 There is no mention of biopsy, excision of lesion, or occlusion
To use a data element for aggregation and reporting, the data element must be:
a. Abstracted or indexed
b. Searched
c. Subject to case finding
d. Registered - Answers a Abstracting is the process of extracting elements of data from a source
document and entering them into an automated system.
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the
following would apply for correct coding?
a. Two CPT codes, one for each laceration
b. One CPT code for the largest laceration
c. One CPT code for the most complex closure
d. One CPT code, adding the lengths of the lacerations together - Answers d. One CPT code, adding the
lengths of the lacerations together. The length of multiple lacerations located in the same classification
are added together for one code.
Which of the following provides a means to record information about patients treated for substance
abuse and mental disorders?
a. Current Procedural Terminology
b. Diagnostic and Statistical Manual of Mental Disorders, 4th Revision
c. ICD-10-CM
d. Systematized Nomenclature of Medicine Clinical Terminology - Answers b. Diagnostic and Statistical
Manual of Mental Disorders, 4th Revision (DSM-IV-TR)
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 other data and to provide weekly productivity reports and analyses. Which of the
following tools would be best to use for this purpose?
a. Database management system
b. Paper log book
c. Spreadsheet
d. Word-process documents - Answers a. Database management system
Which of the following is a goal of ICD-10-PCS?
a. Assign diagnosis codes
b. Eliminate the need to communicate with physicians
c. Reduce inconsistency due to overlapping of terms
d. Assign diagnosis and procedure codes - Answers c. Reduce inconsistency due to overlapping of terms.
According to CMS, the design of ICD-10-PCS includes the following goals: to improve accuracy and
efficiency of coding, to reduce training effort, and to improve communication with physicians
Which of the following elements of coding quality represent the degree to which the codes capture all
the diagnosis and procedures documented in the patient's health record?
a. Completeness
b. Reliability
c. Timeliness
,d. Validity - Answers a. Completeness is the degree to which the code assignments captures all the
diagnoses and procedures documented in the health record.
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 - Answers c. Identify unbundling of codes. The latest
version of the Medicare integrated outpatient code editor (IOCE) should be installed to review claims
prior to releasing billed data to the Medicare program. IOCE software contains the NCCI edits for CPT.
A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver
cancer. IV fluids were administered to the patient. Which of the following should be sequenced as the
principal Dx?
a. Dehydration
b. Chemotherapy
c. Liver carcinoma
d. Complication of chemotherapy - Answers a. Dehydration. When the admission or encounter is for
management of dehydration due to malignancy and only the dehydration is being treated, the
dehydration is sequenced first, followed by the code(s) for malignancy.
The APC payment system is based on what coding system?
a. CPT/HCPCS codes
b. ICD-10-CM diagnosis and procedure codes
c. CPT and ICD-10-CM procedure codes
d. Only CPT codes - Answers a. CPT/HCPCS codes are how the calculation for payment of services are
based. Catergorization of outpatient services into APC groups are based on CPT/HCPCS codes.
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. DRG - Answers c Principal diagnosis. To begin the review, the coding supervisor checks the inpatient
record to ensure that the diagnosis billed as the principal Dx meets the UHDDS definition for principal
Dx.
A patient was seen in the ER for chest pain. It was suspected that the patient may have GERD. The final
diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is:
a. K21.9, Gastroesophageal reflux disease without esophagitis
b. R07.9, Chest pain, unspecified
c. R10.11, Right upper quadrant pain
d. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out - Answers b.
R07.9, Chest pain, unspecified. Because this is an outpatient visit, a diagnosis wiith "probable" or
"questionable" can not be coded as being definitive. Instead, code to highest level of certainty.
Coding accuracy is best determined by:
a. A predefined audit process
b. Medicare Conditions of Participation
c. Payer audits
d. Joint Commission Standards for Accreditation - Answers a. A predefined audit process. Coders should
be evaluated at least quarterly with appropriate training needs identified, facilitated, and reassessed
over time. Only through this continuous process of evaluation can quality and integrity be measured and
ensured.
Complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port;
replacement performed through original access site (45yo patient). Which of the follow CPT codes is
most appropriate?
36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump,
central or peripheral insertion site
36580 Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access
36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with
subcutaneous port, through the same venous access
36597 Repositioning of prevously placed central venous catheter under fluoroscopic guidance
a. 36578
b. 36580
, c. 36582, 36597
d. 36582 - Answers d. 36582 Complete replacement of entire device by the same venous access site;
tunneled catheter inserted within the same venous access point
A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment?
49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of
specimen(s) by brushing or washing (separate procedure)
58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvis viscera, or
peritoneal surface by any method
58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671 Laparoscopy, surgical; with occlusions of oviducts by device (eg. band, clip, or Falope ring)
a. 49320, 58662
b. 58670
c. 58671
d. 49320 - Answers b. 58670 There is no mention of biopsy, excision of lesion, or occlusion
To use a data element for aggregation and reporting, the data element must be:
a. Abstracted or indexed
b. Searched
c. Subject to case finding
d. Registered - Answers a Abstracting is the process of extracting elements of data from a source
document and entering them into an automated system.
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the
following would apply for correct coding?
a. Two CPT codes, one for each laceration
b. One CPT code for the largest laceration
c. One CPT code for the most complex closure
d. One CPT code, adding the lengths of the lacerations together - Answers d. One CPT code, adding the
lengths of the lacerations together. The length of multiple lacerations located in the same classification
are added together for one code.
