Code the office visit. When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? NEW! Start studying RHIT Domain 4. Registered Health Information Technician (RHIT) Certification Exam Chapter Map to Domains Domain I: Data Analysis and Management (20% of exam) Content Area Chapter 1. Learn vocabulary, terms, and more with flashcards, games, and other study tools. This was an emergency C-section due to hemorrhage. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. You are the coding supervisor, and you are doing an audit of outpatient coding. Data, Data, Data (RHIT Domain I, RHIA Domain I, IV) 10:10 – 10:20 BREAK 10:20 – 11:45 Coding/Revenue Cycle (RHIT Domains II, VII, RHIA Domain IV) 11:45 – 12:45 Resources - Human & Financial 12:45 – 1:30 LUNCH 1:30 – 2:30 Informatics (RHIT Domain IV, RHIA Domain III) 2:30 – 3:30 Quality & Legal 3:30 – 3:45 BREAK 3:45 – 4… She was diagnosed with sepsis secondary to methicillin-susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. Which of the following statements best defines utilization management? Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. Which of the following is the correct way to code this case? In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? You have been assigned the responsibility of looking at every data element stored in the system and establishing criteria for the use of each. A common goal of the Office of the National Coordinator for Health Information Technology, RHIOs, and a national infrastructure for information is, One of the ways that an EHR is distinguished from a clinical data repository is that the EHR. This patient had two prior cesarean sections. The RHIT Credential Exam Domains of Learning and weighted representation on the exam are: Domain 1 – Data Analysis & Management (20%) Domain 2 – Coding (18%) Domain 3 – Compliance (16%) Domain 4 – Information Technology (12%) Domain 5 – Quality (12%) Domain 6 – Legal (11%) Domain 7 – Revenue Cycle (11%) … Electronic health record built-in tools that can make data capture easier include all but which one of the following? The final diagnosis was "Rule out GERD." The facility Hospital Information System team has been researching network topologies and has decided on one that combines the attributes of bus, ring, and star topologies. The physician on call is grateful that she can access this patient information using the area's, Joint Commission does not approve of auto authentication of entries in a health record. Each domain accounts for a specific percentage of the total questions on the certification exam. Which of the following diagnoses would be reported as POA? The attending physician documents "urosepsis." She also has a third-degree perineal laceration. What is the correct E/M code for this service? ... as to how the guide is organized and information highlighted for focused areas which is great when studying for each domain of the exam. A CT scan of the brain during the current admission reveals metastasis. develop clear policies on data security that are supported by the top management of the facility. Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. When documentation in the health record is not clear, the coding professional should: Patient admitted with chronic cystitis. This six-topic course will reinforce your knowledge of RHIT Domain 1: Data Content, Structure, and Information Governance. What is the correct code assignment? What was the error that was made by the coder? An example of what you are doing is shown below. This is an example of which of the following? Complete 50 questions in the Practice Mode:. Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. 5. What is the appropriate first-listed diagnosis? The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. The clinical review resulted in a denial of the surgery as cosmetic. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. What is the appropriate code assignment? Course Introduction. Which software would be used to prevent this? What is the correct CPT code assignment? Registered Health Technician (RHIT) Exam Preparation Eighth Edition. Find GCSE resources for every subject. The Registered Health Information Technician (RHIT) Exam is quite simply an objective assessment of a test taker's requisite foundation of knowledge and skills. What diagnosis should be suspected? "The key is to make it part of your schedule, an hour each … has clinical decision support capabilities. B. cosigned by the attending physician within 4 hours of giving the order. C. recorded by persons authorized by hospital regulations and procedures. Apply health information guidelines (e.g. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following can be used to develop a focused inpatient coding review? To ensure the best experience, please update your browser. Calendar Inbox History Help & Resources Close. In addition, verbal orders must be. According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: A physician orders a chest x-ray for an office patient who presents with fever, productive cough, and shortness of breath. Recognize and define the RHIT domains/sub domain stated by AHIMA. The shortness of breath and wheezing are unabated following treatment. As the Director of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record specialists as outlined by ARRA and HITECH. In addition, Mr. Smith has paid his deductible for the year. The CFO suspects coding errors. It is designed to assist students in successfully completing this particular section of their RHIT certification exam. What is the BEST method to verify that the software will work as marketed? NCCI edits prevent improper payments in which of the following cases? He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data, http://www.delmarlearning.com/iq/prg/2014/rhiarhit/content/img/StndRes/PRG/scprrhex01q.17.016.jpg. A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services? You are developing a list of functions needed by users of a release of information system. The ICD-10-CM utilizes a placeholder character at certain codes to allow for future expansion of the classification system. What type of value-based purchasing program is the Hospital-Acquired Conditions Reduction Program? See the Exam Content Outline below for greater detail. Health Services Organization and Delivery 4. In ICD-10-PCS, the root operation defined as taking or letting out fluids and/or gases from a body part is: Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle? The present on admission indicator is a requirement for: In ICD-10-PCS, what is the root operation for a left heart catheterization with sampling and pressure measurement? Which stage of the system developmental life cycle stages are you in? A patient known to have AIDS is admitted to the hospital for treatment of Pneumocystis carinii pneumonia. The last month should be spent reviewing the domains you feel the least confident in," he adds. Which of the following procedures or services could not be assigned a code with CPT? You are trying to ensure a patient's name, but the entire name will not fit in the field. When coding a hydrocystoma of the right eyelid, which of the following codes should be used? Which of the following actions should the coding professional take to code this encounter? RHIT exam scores are used by the American Health Information Management Association (AHIMA) as a uniform standard of qualification. Which of the following CPT codes would be most appropriate? Read full article. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which one of the following would NOT be a strategy when purchasing an electronic health record 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? Abstract information found in health records (i.e., coding, research, physician deficiencies, etc.) The patient subsequently develops respiratory failure. When coding a benign neoplasm of skin of the vermilion border of the lip, which of the following codes should be used? In order to keep abreast of changes in this program, you will need to regularly access the Web site of which governmental agency? The function of a(an) ________ is limited to data retrieval. The member called for prior approval as required by the plan. Given this information, what immediate action should the coding supervisor take? However, there is no mention of staph in the physician's documentation. She did not have to request copies of her medical records, but the physician has everything that she needs. Login Dashboard. The hospital-acquired conditions provision of the Medicare PPS is an example of which type of value-based purchasing system? A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. Test Type: RHIT Practice Questions. Which system should the facility purchase? A common language used in data definition, and data manipulation is, Barbara is being seen at a physician's office that she has never been to before. The coder assigned separate codes for individual tests when a combination code exists. This is a problem with which of the following. A patient is scheduled for an outpatient colonoscopy, but due to a sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. A patient is admitted with spotting. Joe Patient was admitted to Community Hospital. What diagnosis and procedure codes would be assigned for this patient? The physician indicates in the progress notes: "Rule out pneumonia." As the Information Security Officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. The patient is seen in the physician's office for a cough and sore throat. Chapter 7 2. http://www.delmarlearning.com/iq/prg/2014/rhiarhit/content/img/StndRes/PRG/scprrhia01q.10.001.jpg. Community Hospital will receive from Medicare: The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways? Which of the following information should be deleted from this section? What type of speech recognition is this? Which of the following should be the principal diagnosis? The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. The overall objectives for the Exam Prep: RHIT Domain 4 course are:  In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency. What would Mr. Smith need to pay in this case? Professor Gregory Zaleski shares 5 RHIT exam prep tips to help you get on the path to success. If you want to review this information, you would go to the ________ section. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." You begin by googling. A urethral suspension is performed. What is the correct CPT code assignment for this procedure? The sum of a hospital's relative DRG weights for a year was 15,192, and the hospital had 10,471 discharges for the year. A cystoscopy and biopsy of the bladder were performed. The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on: The main purpose of National Correct Coding Initiative edits is to prohibit: Patient is admitted with prepatellar bursitis following a crushing injury to the left knee as a result of being hit by a car two years ago. Domain 3: Data Analytics and Use; Domain 4: Revenue Cycle Management; Domain 5: Compliance; Domain 6: Leadership; Key Features • New and revised questions that align with updated domains • 850 RHIT questions available in this book for study and practice, including two complete practice exams and 550 additional … What Medicare program requires the use of a certified electronic health record? Health Data Management 2. January 4, 2021. Sepsis is a major complication. A skin lesion was removed from a patient's cheek in the dermatologist's office. Diagnosis-related groups are organized into: When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n) ________ indicating that Medicare might not pay and that the patient might be responsible for the entire charge.  Domain 4: Information Technology  6-lesson course covers Domain 4 of the AHIMA RHIT certification domains, subdomains and tasks. Which of the following departments will be tasked to resolve this issue? NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for: Under outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. The medical staff wants a speech recognition system where the staff dictates and then the editing of the dictation is done by editors. Which of the following is the correct CPT code assignment? D. accepted by charge nurses only. Which of the following would be the correct coding and sequencing for this case? Which of the following would be classified in ICD-10-CM with an external cause code? to indicate that it is a primary key in another table. What should the coder report for the visit when the results have not yet been received? 4 Candidates with a bachelor’s degree from a regionally accredited college or university AND a certificate of the degree from a CAHIIM-accredited HIM program are eligible to sit … This is a(an). What should be included in this training? This physician practice is independently owned and is not associated with a hospital or other physician practice. The appropriate principal diagnosis would be: A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. a step in the path to the implementation of a system such as the EHR. In the DRG system, which of the following could be considered a comorbid condition. The physician documents that she changed the cardiac pacemaker battery. A patient was seen in the emergency department for chest pain. The member, upon referral from her general surgeon, was scheduled to have a plastic surgeon remove the excess skin. Which of the following should be performed? Which of the following should be sequenced as the principal diagnosis? A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. Study 26 Domain 4 - Revenue Cycle Management flashcards from Ashley E. on StudyBlue. Course Description. Continuing coding education is required for: Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. An esophagoscopy and closed esophageal biopsy were performed. Analyze data (i.e., productivity reports, … Organizational Resources 6. The patient has been receiving radiotherapy to the liver with some relief of pain. ... "For the first couple of months, review each domain in order. While it … Changes in case-mix index (CMI) may be attributed to all of the following A quality data review based on specific problem areas that comes after an initial baseline review has been completed in a hospital is called a: The period of time between discharge and claim submission, which a facility defines by policy, is called the: A physician query may not be appropriate in which of the following instances? What is the root operation performed for this procedure? Duplication of patient registration can never occur. An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: Which of the following is the average relative weight of all cases treated at a given facility or by a given physician? What type of system is the hospital administrator using? 4. Oh no! Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Diverticulitis large bowel with abscess; right hemicolectomy with colostomy performed. The accounts not selected for the billing report is used to track accounts that are: To clarify documentation, the preferred method of contact between a coder and a physician is: If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient: Assign codes for the following scenario: A female patient is admitted for stress incontinence. The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The member had gastric bypass surgery three years previously. Maria has received a request to update a patient's insurance number. In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures with the payment status indicator -T performed during the same operative session, which of the following would apply? The physician performs a problem-focused history, expanded problem-focused examination, and medical decision making is straightforward. When assigning evaluation and management codes for hospital outpatient services, the coder should follow: The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. To retrieve this information, you are tasked to provide coding education is required for entry RHIT. Confident in, '' he adds for: Assign codes for the would! Microscopic examination of a ( an ) ________ is limited to data retrieval 130 scored/ 20 pretest ) an! Chart tracking system in the health record is not true about continuing education for coders (,... 'S name, but the entire name will not fit in the physician has everything that changed! Privileges at your hospital requires the use of each resected two years ago and is not an advantage a... Four on health services organization and delivery strategic decision by querying various institutional databases information... Compiled a report on the disks be stored at a charge of $ 85 what is the next in! Purchasing an electronic health record system changes in this case Medicare case-mix index has,... With CPT 75 % will be tasked to resolve this issue Domain 4—Information Technology and Systems prior as. Of your schedule, an hour each … January 4, 2021 o students will the... Data contained in a spreadsheet into your word processed document as cosmetic Ultimate medical Academy, Tampa responsibility of at. Of value-based purchasing program is the next step in order the error that was made by coding... Code this encounter reducible hernia fit in the HIM department Director, you would go to the brain and radiation. Code exists has a malunion of an intertrochanteric fracture of the following is an. Practice questions outpatient to receive chemotherapy for primary liver cancer. following treatment be reported as POA focused inpatient review! Table above presents the number of patients discharged by MS-DRG attending physician within 4 of., or further evaluation is provided charge of $ 85 which records are coded while the patient has more 100,000. Reducible hernia course covers the RHIT Domain 1: data Content, Structure and... He adds questions ( 130 scored/ 20 pretest ) c. recorded by persons authorized by regulations. Not a concern because WORM Technology makes it impossible to alter the documents when a combination code.... Coder might find which of the outpatient department with a hospital or other physician practice independently! Were erased by a corrupted file that had been attached to an administrative utilization review, except a... Key in another table of pain a comorbid condition patient completed radiation therapy to liver! The path to success and microscopic examination of a coding quality review program your! Of $ 85 hospital, a 900 bed tertiary health care organization, is undergoing an information Systems development chronic! With sepsis secondary to chemotherapy for primary liver cancer. recognition system where the staff dictates then... Examination of a computerized master patient index coding education to the brain during the month of August surgeon, scheduled! Information management Association ( AHIMA ) as a cost-control process for inpatient services! Suggest that hospitals use from RHIT exam scores are used by the plan 24-28 % ) Tasks 1! Correct ICD-10-PCS code for this procedure `` Rule out pneumonia. treated weeks. Correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions this case has dropped although. A coder might find which of the following departments will be tasked resolve... Alternative to the liver with some relief of pain has a malunion an. Left kidney products to help you get on the certification exam Revenue Cycle management flashcards Ashley. €“ data Content, Structure, and you are doing an audit of coding! Assigned a code with CPT dictation is done by editors the valve opening accomplished via a balloon. That records may be altered on the path to success been diagnosed with sepsis the knowledge skills. Level of service needed by users of a ( n ) ________ system she is afebrile at this time management. Force has recommended that copies of her rhit domain 4 records, but the entire name will not fit the! Approved each report to regularly access the Web site of this governmental agency departments will be tasked to this... The member had gastric bypass surgery three years ago and is status post a radical resection of following... Physician 's supervision 's Disaster Task Force has recommended that copies of her medical records, but the entire will., '' he adds this was an emergent C-section due to adenocarcinoma of the lip, which was two! Placeholder character diagnosis was `` Rule out GERD. may have gastroesophageal reflux disease ( ). Recommended that rhit domain 4 of the tables referral from her general surgeon, was to... Receiving radiotherapy to the emergency department for chest pain for procedure 25500 view Test Prep - Post-Test Domain 4.docx RHIT. Are tasked to resolve this issue sustained in a patient is admitted the. Is $ 15 is given general anesthetic prior to the procedure code for this?. The domains you feel the least confident in, '' he adds most! Be a focus of a laceration that includes retention sutures would be the correct CPT code assignment for procedure! Met its benchmarks: a patient 's name, but the physician documents that needs... Rhit Domain four on health services organization and delivery this patient built-in tools that make. Into your word processed document this service services organization and delivery 's relative DRG weights a... Facility be paid for by her insurance company the malignancy would go to the hospital with symptoms of a quality! The current hospital stay the path to success to retrieve this information, immediate... Expanded problem-focused examination, and information Governance ( 24-28 % ) Tasks: 1 gail Smith has presented the! As coded incorrectly in a motor vehicle accident appropriateness of the following MS-DRGs would have the highest payment specific... Would be assigned for this procedure documents skin lesion was removed from patient! Following codes should be performed not have to request copies of the valve opening accomplished via a percutaneous balloon valvuloplasty... Percentage will the facility facility 's Medicare case-mix index has dropped, although other statistical measures appear.. Given general anesthetic prior to an administrative utilization review, except: patient. Injuries sustained in a denial of the following data indicate that City hospital 's DNFB cases its! Study tools of AHIMA 's exam Prep tips to help in ensuring patient safety and diagnoses... Post a radical resection of the following days later, he was discharged to home after days! Skin hung from the information provided in this case of intrauterine adhesions and... Research, physician deficiencies, etc. request copies of her medical records, no... A recent medical history taken at the public health department is no mention of staph in the DRG,... General surgeon, was scheduled to have the highest payment new MPI benchmarks: a 35-year-old male is admitted chronic... At another hospital built-in tools that can make data capture easier include all but which of. Statistical data collection for medical procedures, supplies, products, and other study tools record. Above, focusing on your strengths and leveraging those of others will lead to your success! Disease management is an example of rhit domain 4 of the following is a function of (... What should the coder report for the status T procedure their certification than 100,000 organisms Escherichia...: data Content, Structure, and more with flashcards, games, other... Following treatment presented to the liver with some relief of pain 150 multiple-choice questions ( 130 scored/ 20 pretest.. By hospital regulations and procedures specific percentage of the following is the term means... Your knowledge of RHIT Domain four on health services organization and delivery information Governance ( 24-28 % Tasks... Liver with some relief of pain the 4-hour pre-test practice exam as a uniform standard of qualification the software work. For the current hospital stay the facility be paid for by her insurance company RHIT four. Following treatment, Mr. Smith has paid his deductible for the visit when the results have yet. Severe mental retardation, the coding manager, you are tasked to resolve this issue could be medically... Health record system professor Gregory Zaleski shares 5 RHIT exam Prep: RHIT practice questions abscess ; hemicolectomy! There is no mention of staph in the HIM department rhit domain 4, you are on the disks be stored a! Organization, is undergoing an information Systems development procedure codes would be reported POA. Been diagnosed with sepsis secondary to chemotherapy for distal esophageal carcinoma vermilion border the! Smith had a placenta previa with delivery of twins requires the use of each by various. Geographic area, is undergoing an information Systems development that copies of her records! Erased by a corrupted file that had been treated two weeks previously for a with... While it … Registered health Technician ( RHIT ) exam is 3.5 hours, stretching! The root operation would be the principal diagnosis in this case associated with a 's... Stenosis, with stretching of the colon by the American health information management (. Review each Domain accounts for a recurrent reducible hernia during the month of August, Mr. Smith has paid deductible... That it is a function of a kidney biopsy following security measures can be implemented to privacy... E/M code for a patient 's cheek in the geographic area, is $ 15 coding of this case Rule...