AHIMA RHIT Exam 2026 — 100 Practice
Questions With Answers
DOMAIN 1 — DATA CONTENT, STRUCTURE & INFORMATION GOVERNANCE
1. Which document in the health record typically contains the patient's presenting complaint?
A. Operative report
B. History and physical ✓
C. Discharge summary
D. ED nursing notes
2. Which classification system is used for reporting inpatient procedures in the U.S.?
A. CPT
B. HCPCS
C. ICD-10-PCS ✓
D. CDT
3. The UHDDS applies to which type of patient?
A. Outpatient
B. Ambulatory surgery
C. Home health
D. Hospital inpatient ✓
4. In ICD-10-CM, the placeholder “X” is used for:
A. Main terms
B. Excludes1 notes
C. Future expansion ✓
D. Manifestation codes
5. The legal health record is defined by:
A. The health system’s IT vendor
B. The state health department
C. Organizational policy and HIPAA ✓
D. CMS only
6. What type of data are blood pressure readings?
A. Nominal
,B. Ordinal
C. Continuous ✓
D. Discrete
7. A physician's handwritten note stored electronically as a scan is called:
A. Structured data
B. Unstructured data ✓
C. Normalized data
D. Abstracted data
8. What part of the record documents diagnostic and therapeutic procedures chronologically?
A. Nursing notes
B. Physician orders
C. Progress notes ✓
D. Lab results
9. A data dictionary ensures:
A. Patient satisfaction
B. Standard definitions across systems ✓
C. Billing accuracy only
D. Enhanced security only
10. A cardinal rule for record integrity includes:
A. Allowing edits without tracking
B. Capturing who, what, when of changes ✓
C. Hiding incomplete entries
D. Deleting old versions permanently
DOMAIN 2 — ICD-10-CM/PCS & CPT CODING
11. CPT Category II codes are used for:
A. Reimbursement
B. Quality measurement ✓
C. Anesthesia services
D. Emerging technology
12. A coder reviews documentation to assign codes. What process is this?
A. Re-abstracting
B. Case management
,C. Clinical coding ✓
D. Clinical validation
13. A hospital-acquired condition (HAC) affects:
A. MS-DRG assignment ✓
B. Outpatient E/M codes
C. CPT modifiers
D. Discharge status codes
14. ICD-10-CM Z codes represent:
A. Surgical procedures
B. Preventive services
C. Factors influencing health status ✓
D. Manifestation codes
15. Medical necessity is supported by:
A. HCPCS Level II
B. ICD-10-CM codes ✓
C. CPT only
D. Physician credentials
16. In CPT, modifier -59 represents:
A. Bilateral procedure
B. Distinct procedural service ✓
C. Multiple surgeons
D. Professional component
17. POA indicator “N” means:
A. Condition present on admission
B. Clinically undetermined
C. Not present on admission ✓
D. Exempt
18. DRGs are primarily used for:
A. Outpatient payment
B. Inpatient payment ✓
C. Physician payment
D. DME claims
19. Clinical validation ensures:
A. Codes match documentation ✓
, B. The bill is paid
C. Forms are signed
D. The claim is submitted electronically
20. For outpatient surgery, the principal diagnosis is:
A. Reason for admission
B. Condition established after surgery
C. First-listed diagnosis ✓
D. Chronic condition
DOMAIN 3 — REVENUE CYCLE MANAGEMENT
21. The UB-04 is used for:
A. Physician claims
B. Hospital billing ✓
C. Pharmacy billing
D. Hospice only
22. The chargemaster contains:
A. ICD-10-CM codes
B. Itemized services & prices ✓
C. Physician attendance
D. Nursing care plans
23. Clean claims are:
A. Paid immediately
B. Submitted by mail
C. Free of errors and ready for processing ✓
D. Always denied
24. The process of converting services into billable codes is:
A. Abstracting
B. Claim scrubbing
C. Charge capture ✓
D. Utilization review
25. NCCI edits prevent:
A. Fraudulent claims
B. Duplicate or inappropriate CPT coding ✓
Questions With Answers
DOMAIN 1 — DATA CONTENT, STRUCTURE & INFORMATION GOVERNANCE
1. Which document in the health record typically contains the patient's presenting complaint?
A. Operative report
B. History and physical ✓
C. Discharge summary
D. ED nursing notes
2. Which classification system is used for reporting inpatient procedures in the U.S.?
A. CPT
B. HCPCS
C. ICD-10-PCS ✓
D. CDT
3. The UHDDS applies to which type of patient?
A. Outpatient
B. Ambulatory surgery
C. Home health
D. Hospital inpatient ✓
4. In ICD-10-CM, the placeholder “X” is used for:
A. Main terms
B. Excludes1 notes
C. Future expansion ✓
D. Manifestation codes
5. The legal health record is defined by:
A. The health system’s IT vendor
B. The state health department
C. Organizational policy and HIPAA ✓
D. CMS only
6. What type of data are blood pressure readings?
A. Nominal
,B. Ordinal
C. Continuous ✓
D. Discrete
7. A physician's handwritten note stored electronically as a scan is called:
A. Structured data
B. Unstructured data ✓
C. Normalized data
D. Abstracted data
8. What part of the record documents diagnostic and therapeutic procedures chronologically?
A. Nursing notes
B. Physician orders
C. Progress notes ✓
D. Lab results
9. A data dictionary ensures:
A. Patient satisfaction
B. Standard definitions across systems ✓
C. Billing accuracy only
D. Enhanced security only
10. A cardinal rule for record integrity includes:
A. Allowing edits without tracking
B. Capturing who, what, when of changes ✓
C. Hiding incomplete entries
D. Deleting old versions permanently
DOMAIN 2 — ICD-10-CM/PCS & CPT CODING
11. CPT Category II codes are used for:
A. Reimbursement
B. Quality measurement ✓
C. Anesthesia services
D. Emerging technology
12. A coder reviews documentation to assign codes. What process is this?
A. Re-abstracting
B. Case management
,C. Clinical coding ✓
D. Clinical validation
13. A hospital-acquired condition (HAC) affects:
A. MS-DRG assignment ✓
B. Outpatient E/M codes
C. CPT modifiers
D. Discharge status codes
14. ICD-10-CM Z codes represent:
A. Surgical procedures
B. Preventive services
C. Factors influencing health status ✓
D. Manifestation codes
15. Medical necessity is supported by:
A. HCPCS Level II
B. ICD-10-CM codes ✓
C. CPT only
D. Physician credentials
16. In CPT, modifier -59 represents:
A. Bilateral procedure
B. Distinct procedural service ✓
C. Multiple surgeons
D. Professional component
17. POA indicator “N” means:
A. Condition present on admission
B. Clinically undetermined
C. Not present on admission ✓
D. Exempt
18. DRGs are primarily used for:
A. Outpatient payment
B. Inpatient payment ✓
C. Physician payment
D. DME claims
19. Clinical validation ensures:
A. Codes match documentation ✓
, B. The bill is paid
C. Forms are signed
D. The claim is submitted electronically
20. For outpatient surgery, the principal diagnosis is:
A. Reason for admission
B. Condition established after surgery
C. First-listed diagnosis ✓
D. Chronic condition
DOMAIN 3 — REVENUE CYCLE MANAGEMENT
21. The UB-04 is used for:
A. Physician claims
B. Hospital billing ✓
C. Pharmacy billing
D. Hospice only
22. The chargemaster contains:
A. ICD-10-CM codes
B. Itemized services & prices ✓
C. Physician attendance
D. Nursing care plans
23. Clean claims are:
A. Paid immediately
B. Submitted by mail
C. Free of errors and ready for processing ✓
D. Always denied
24. The process of converting services into billable codes is:
A. Abstracting
B. Claim scrubbing
C. Charge capture ✓
D. Utilization review
25. NCCI edits prevent:
A. Fraudulent claims
B. Duplicate or inappropriate CPT coding ✓
