Free RHIA Questions and Answers — Questions and Answers
Question 1: Known or suspected prenatal abnormalities affecting the mother codes from category 655 should
- be assigned when they affect the management of the mother (Correct answer)
- never be assigned
- be assigned if the fetal conditions are documented
- be assigned at the discretion of the physician
Correct answer: be assigned when they affect the management of the mother
In ICD-9-CM coding, categories like 655 (Known or suspected fetal abnormality affecting management of mother) are assigned when the fetal condition directly impacts the management or care provided to the mother during pregnancy, childbirth, or the puerperium. The key criterion is that the fetal abnormality influences the clinical decisions or interventions for the mother, not merely its presence.
Question 2: Edward was diagnosed with congestive heart failure and acute pulmonary edema when he was released from the hospital. Edward's record is being coded by you, and you will code
- the edema only
- both the CHF and the edema; sequence the CHF first
- both the CHF and the edema; sequence the edema first
- the CHF only (Correct answer)
Correct answer: the CHF only
When a patient is discharged with both congestive heart failure (CHF) and acute pulmonary edema, and the pulmonary edema is a direct manifestation or complication of the CHF, the CHF is coded as the principal diagnosis. Acute pulmonary edema is a common symptom of decompensated CHF, so the underlying CHF is considered the primary reason for the hospitalization. Therefore, only the CHF is coded as the principal diagnosis, with acute pulmonary edema as a secondary diagnosis.
Question 3: Special precautions must be taken to prevent the stamp from being used by a delegate when personal signature stamps are used to authenticate entries in a paper-based record. Similar controls might be used to control the usage of electronic medical records in a fully computerized patient record system.
- voice recognition systems
- expert systems.
- electronic signatures (Correct answer)
- fingerprint signatures
Correct answer: electronic signatures
In a fully computerized patient record system, electronic signatures serve the same purpose as personal signature stamps in paper-based records: to authenticate entries. Similar to controlling the use of a physical stamp, robust controls for electronic signatures, such as unique user IDs, passwords, and audit trails, are crucial to ensure the integrity, authenticity, and non-repudiation of entries and prevent unauthorized use or delegation.
Question 4: When an exploratory laparotomy is performed then a therapeutic procedure, the coder reports this information in ICD-9-CM.
- Normalization
- Attributes
- Schema mapping (Correct answer)
- Cardinality
Correct answer: Schema mapping
When an exploratory laparotomy is performed followed by a therapeutic procedure, the coder reports this information in ICD-9-CM by assigning codes for both procedures. In the context of health information systems, 'Schema mapping' refers to the process of defining how data elements from one data model (e.g., clinical documentation of procedures) are translated and stored according to another data model (e.g., the database schema used for ICD-9-CM codes). This ensures that the coded information about both procedures is correctly captured and linked within the system.
Question 5: All lab results from one hospitalization must be rapidly compared by a health record analyst. The paper-based health record design that works well for this objective is
- integrated
- integrated (Correct answer)
- source-oriented (Correct answer)
- problem-oriented
Correct answer: integrated
The integrated health record design works well for rapidly comparing all lab results from one hospitalization. In an integrated record, all forms and documents, regardless of their source (e.g., physician notes, nursing notes, lab results), are arranged in strict chronological order. This chronological flow allows a health record analyst to easily review and compare all lab results sequentially, providing a comprehensive overview of the patient's laboratory data over time.
Question 6: Continuous record reviews are a crucial technique for guaranteeing data quality by using accurate medical records. These evaluations assess
- adverse effects and contraindications of drugs utilized during hospitalization
- potentially compensable events
- completeness, adequacy, and quality of documentation (Correct answer)
- quality of care through the use of pre-established criteria
Correct answer: completeness, adequacy, and quality of documentation
Continuous record reviews are a fundamental quality assurance process in healthcare. Their primary purpose is to systematically evaluate the completeness, adequacy, and overall quality of patient health record documentation. This ensures that the information is accurate, reliable, and meets established standards for patient care, legal requirements, and billing integrity.
Question 7: A new patient with an ulcerative sore on the hip who was residing in a nursing home received medical attention from the doctor. A straightforward medical choice was made after a problem-focused history and physical examination.
- 99324
- 99334 (Correct answer)
- 99325
- 99332
Correct answer: 99334
CPT code 99334 is specifically designated for an initial nursing facility visit for a new or established patient. The description matches the code's requirements: a problem-focused history and examination, along with straightforward medical decision making. The other codes are either for higher complexity initial visits (99324, 99325) or for subsequent visits (99332).
Free RHIA Questions and Answers
Known or suspected prenatal abnormalities affecting the mother codes from category 655 should