RHIT - Registered Health Information Technician Registered Health Information Technician Medical Coding Principles 1 — Questions and Answers
Question 1: Which coding guideline applies when a patient is admitted for a complication of a surgical procedure performed during a prior hospitalization?
- Code the original condition that prompted the initial surgery as the principal diagnosis
- Code the complication as the principal diagnosis (Correct answer)
- Code the surgical procedure code as the principal diagnosis
- Assign an external cause code as the principal diagnosis
Correct answer: Code the complication as the principal diagnosis
When a patient is admitted specifically because of a postprocedural complication, the complication itself is sequenced as the principal diagnosis per ICD-10-CM Official Guidelines.
Question 2: In CPT coding, what distinguishes a 'new patient' from an 'established patient' for E/M office visit codes?
- A new patient has never visited any provider in the same specialty within the same group practice in the past 3 years (Correct answer)
- A new patient has never visited the specific physician before, regardless of group affiliation
- A new patient has not been seen by the practice in the past 12 months
- A new patient is one whose medical records have not yet been transferred to the practice
Correct answer: A new patient has never visited any provider in the same specialty within the same group practice in the past 3 years
CPT defines a new patient as one who has not received face-to-face professional services from the physician or any physician of the same specialty in the same group practice within the past three years.
Question 3: Under the ICD-10-PCS structure, which axis (character) specifies the operative approach used in a procedure?
- Character 3 — Root Operation
- Character 4 — Body Part
- Character 5 — Approach (Correct answer)
- Character 6 — Device
Correct answer: Character 5 — Approach
In ICD-10-PCS, the seven-character code structure assigns Character 5 to Approach, which describes how the operative site is accessed (e.g., Open, Percutaneous, Endoscopic).
Question 4: A patient is admitted with chest pain. Workup reveals the chest pain is due to gastroesophageal reflux disease (GERD). Which condition should be coded as the principal diagnosis?
- Chest pain, unspecified
- GERD, without esophagitis (Correct answer)
- Chest pain due to GERD — both coded equally
- Atypical chest pain with secondary GERD
Correct answer: GERD, without esophagitis
When the workup during an inpatient stay identifies the underlying cause of a symptom, the confirmed underlying condition (GERD) is sequenced as the principal diagnosis rather than the presenting symptom (chest pain).
Question 5: What is the primary purpose of the Uniform Hospital Discharge Data Set (UHDDS) in inpatient coding?
- To establish fee schedules for hospital reimbursement
- To define standardized data elements and their definitions for inpatient hospital reporting (Correct answer)
- To provide clinical documentation templates for physicians
- To set maximum length-of-stay benchmarks by DRG
Correct answer: To define standardized data elements and their definitions for inpatient hospital reporting
The UHDDS establishes minimum common data elements—including the definition of principal diagnosis, other diagnoses, and procedures—that must be reported consistently for inpatient hospital discharges.
Question 6: When coding neoplasm-related encounters, which sequencing rule applies when a patient is admitted solely to receive chemotherapy for a known malignancy?
- Sequence the malignancy as the principal diagnosis and chemotherapy as secondary
- Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis and the malignancy as an additional code (Correct answer)
- Sequence an adverse effect code as the principal diagnosis
- Sequence the neoplasm-related pain as the principal diagnosis
Correct answer: Sequence the encounter for chemotherapy (Z51.11) as the principal diagnosis and the malignancy as an additional code
Per ICD-10-CM Official Guidelines, when the sole reason for admission is to receive antineoplastic chemotherapy, the Z code for the encounter (Z51.11) is the principal diagnosis, with the malignancy coded additionally.
RHIT - Registered Health Information Technician Registered Health Information Technician Medical Coding Principles 1
Which coding guideline applies when a patient is admitted for a complication of a surgical procedure performed during a prior hospitalization?