RHIT - Registered Health Information Technician Medical Coding Principles Questions and Answers — Questions and Answers
Question 1: According to the UHDDS, the definition of Principal Diagnosis is the condition that:
- is the most resource-intensive during the hospital stay.
- is the underlying cause of a manifestation, coded second.
- is established after study to be chiefly responsible for the patient's admission to the hospital. (Correct answer)
- is the first diagnosis documented by the admitting physician in the emergency department.
Correct answer: is established after study to be chiefly responsible for the patient's admission to the hospital.
The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as 'that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.' The other options describe the primary diagnosis, a manifestation, or the admitting diagnosis, respectively.
Question 2: A patient is admitted to the hospital with acute abdominal pain. After evaluation and a CT scan, the physician diagnoses acute appendicitis and performs an appendectomy. What should be sequenced as the principal diagnosis?
- The appendectomy procedure code.
- Acute abdominal pain.
- A code for the CT scan.
- Acute appendicitis. (Correct answer)
Correct answer: Acute appendicitis.
The principal diagnosis is the condition established after study to be the reason for admission. In this case, the abdominal pain was a symptom, and after study, acute appendicitis was the definitive diagnosis that necessitated the admission and procedure. Therefore, acute appendicitis is the principal diagnosis.
Question 3: Which of the following is the primary purpose of CPT modifiers?
- To indicate the severity of a patient's condition.
- To provide additional information about a procedure or service without changing its definition. (Correct answer)
- To specify the final diagnosis for an encounter.
- To replace the need for a written report for a procedure.
Correct answer: To provide additional information about a procedure or service without changing its definition.
CPT modifiers are two-character codes appended to a CPT code to provide additional details about the service performed, such as if it was a bilateral procedure or a reduced service, without altering the core meaning of the code itself.
Question 4: An ICD-10-CM code for a manifestation is being assigned. The coding guidelines and instructional notes in the Tabular List indicate a 'code first' note. What does this convention require the coder to do?
- Sequence the manifestation code as the principal diagnosis.
- Assign only the manifestation code and ignore the underlying disease.
- Sequence the underlying etiology (cause) of the disease first, followed by the manifestation code. (Correct answer)
- Query the physician to determine which code should be sequenced first.
Correct answer: Sequence the underlying etiology (cause) of the disease first, followed by the manifestation code.
The 'code first' instructional note found at the manifestation code in the Tabular List requires the coder to sequence the underlying condition (etiology) before the manifestation code. The manifestation code can never be the principal diagnosis.
Question 5: A patient is admitted with dementia due to Alzheimer's disease. In ICD-10-CM, Alzheimer's disease is the etiology and dementia is the manifestation. How should these conditions be sequenced?
- Code for dementia first, followed by the code for Alzheimer's disease.
- Assign a combination code that includes both conditions.
- Code for Alzheimer's disease first, followed by the code for dementia. (Correct answer)
- Report only the code for dementia as it was the reason for admission.
Correct answer: Code for Alzheimer's disease first, followed by the code for dementia.
According to the ICD-10-CM etiology/manifestation convention, the underlying condition (etiology) must be sequenced first, followed by the code for the manifestation. In this case, Alzheimer's disease (the etiology) is coded first, and the resulting dementia (the manifestation) is coded second.
Question 6: Which of the following conventions is used in ICD-10-CM when the information in the medical record provides detail for which a specific code does not exist?
- NOS (Not Otherwise Specified)
- Brackets [ ]
- NEC (Not Elsewhere Classifiable) (Correct answer)
- Excludes1 note
Correct answer: NEC (Not Elsewhere Classifiable)
The abbreviation NEC, or 'Not Elsewhere Classifiable,' is used when the provider's documentation is specific, but the ICD-10-CM classification system does not have a code that provides that level of specificity. NOS, or 'Not Otherwise Specified,' is used when the documentation itself is not specific enough to assign a more detailed code.
RHIT - Registered Health Information Technician Medical Coding Principles Questions and Answers
According to the UHDDS, the definition of Principal Diagnosis is the condition that: