rhit domain 4

The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following departments will be tasked to resolve this issue? this is not a concern because WORM technology makes it impossible to alter the documents. Which of the following could be a focus of a coding quality review program? Which one of the following would NOT be a strategy when purchasing an electronic health record system? Which of the following is a function of the outpatient code editor? Which of the following actions should the coder take in this case? January 4, 2021. The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: What is the benefit to comparing the coding assigned by coders to the coding appearing on the claim? The peer clinician denied the case. Continuing education is vital to ensure accurate coding. What is the correct code assignment? As HIM Department Director, you are on the implementation team for the new MPI. This six-topic course will reinforce your knowledge of RHIT Domain 1: Data Content, Structure, and Information Governance. What would Mr. Smith need to pay in this case? View Test Prep - Post-Test Domain 4.docx from RHIT EXAM PREP 4444 at Ultimate Medical Academy, Tampa. The patient subsequently develops respiratory failure. This was an emergency C-section due to hemorrhage. The overall objectives for the Exam Prep: RHIT Domain 4 course are:  The first step in an inpatient record review is to verify correct assignment of the: This individual assists in educating medical staff members on documentation needed for accurate coding. What diagnosis should be suspected? The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. http://www.delmarlearning.com/iq/prg/2014/rhiarhit/content/img/StndRes/PRG/scprrhex01q.10.050.jpg. 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. While someone with no relationship building themes is certainly capable of having meaningful and fulfilling relationships, using the four domains will bring awareness … Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services? If you want to review this information, you would go to the ________ section. A facility wants to purchase a system that will use barcodes on all drug and biological products to help in ensuring patient safety. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. The principal diagnosis is acute appendicitis. What system should she use? What is the root operation performed for this procedure? Which system should the facility purchase? Which of the following actions should the coding professional take to code this encounter? The patient has more than 100,000 organisms of Escherichia coli per cc of urine. A 75% will be an indicator of success for passing the AHIMA RHIT credentialing examination. Ureteroscopy with placement of bilateral ureteral stents was performed. This case was identified as coded incorrectly in a recent audit by the coding manager. The last month should be spent reviewing the domains you feel the least confident in," he adds. 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? Health Statistics, Biomedical Research, and Quality Management 3. What types of software provide a front-end structure/interface that presents information in a familiar format leading to a natural style of interaction through the use of icons and a mouse? Registered Health Information Technician (RHIT) Exam Content Outlin e . Diverticulitis large bowel with abscess; right hemicolectomy with colostomy performed. Start studying RHIA Domain 4. 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 physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. 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 Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. A 65-year-old patient with a history of lung cancer is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. Organizational Resources 6. Which of the following can be used to develop a focused inpatient coding review? Changes in case-mix index (CMI) may be attributed to all of the following In CPT, the battery is called a(n): Which of the following would generally be found in a query to a physician? 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? She sees a lab report in a patient's health record that is positive for staph infection. Learn vocabulary, terms, and more with flashcards, games, and other study tools. NCCI edits prevent improper payments in which of the following cases? Upon final review of the RFP that is to be sent out to prospective vendors, you notice that there is content that should not be included in the operational requirement section of the document. Abstract information found in health records (i.e., coding, research, physician deficiencies, etc.) Analyze data (i.e., productivity reports, … A skin lesion was removed from a patient's cheek in the dermatologist's office. Medicare inpatient reimbursement levels are based on: Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? What is the correct CPT code assignment? Domain 1 – Data Content, Structure, and Information Governance (24-28%) Tasks: 1. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. In ICD-10-PCS, what root operation would be coded for this procedure? What is the appropriate code assignment? Learn vocabulary, terms, and more with flashcards, games, and other study tools. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. The Risk Management Committee's Disaster Task Force has recommended that copies of the disks be stored at a facility across town. When coding a benign neoplasm of skin of the vermilion border of the lip, which of the following codes should be used? A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. You can feel confident preparing for the RHIT certification exam using this Registered Health Information Technician (RHIT) Exam Preparation.This book simulates the exam experience by offering two complete practice exams and 850 multiple choice questions that are based on the RHIT … A patient is admitted to the hospital with shortness of breath and congestive heart failure. recorded by persons authorized by hospital regulations and procedures. Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. A patient is admitted with abdominal pain. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency. What is the correct code assignment? Which of the following should be sequenced as the principal diagnosis? You are trying to ensure a patient's name, but the entire name will not fit in the field. 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 … Login Dashboard. Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. Which of the following information should be deleted from this section? Given this information, what immediate action should the coding supervisor take? Oh no! Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system? City Hospital's Revenue Cycle Management team has established the following benchmarks: (1) The value of discharged not final billed cases should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. evidence cannot be provided that the physician actually reviewed and approved each report. A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The pathologist performed a gross and microscopic examination of a kidney biopsy. Which of the following is most likely to be used in performing an outpatient coding review? What diagnosis and procedure codes would be assigned for this patient? The principal diagnosis listed on this admission is: A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). 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. In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? Assign the principal diagnosis for this patient. From the information provided in this table, what percentage will the facility be paid for procedure 25500? Which of the following CPT codes would be most appropriate? The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. C. recorded by persons authorized by hospital regulations and procedures. A patient has liver metastasis due to adenocarcinoma of the rectum, which was resected two years ago. You are also evaluating the current system to see what opportunities there are to improve the system. Which of the following would be the correct sequencing and coding of this case? A hospital can monitor its performance under the MS-DRG system by monitoring its: In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). Given the information here, how much of the APC payment would the facility receive for the status T procedure? All of the following are steps in medical necessity and utilization review, except: A laparoscopic tubal ligation is undertaken. When coding a benign neoplasm of skin of the left eyelid, which of the following codes should be used? This course was developed as part of AHIMA's Exam Prep series for certification exams. The physician must be part of a(n), As supervisor of the cancer registry, you report the registry's annual caseload to administration. The Impact of COVID-19 on Health Information 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. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. The sepsis had resolved, and she is afebrile at this time. To ensure the best experience, please update your browser. What practice do HIM departments use to protect themselves from RAC identifying coding and billing errors? 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. Grading Scale Which of the following is the correct CPT code assignment? The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. An example of what you are doing is shown below. 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. The correct ICD-10-CM diagnosis code is: In the inpatient prospective payment system, the calculation of the DRG begins with the: What factor is medical necessity based on? 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 is the procedure code for a patient who had ventilator management for more than 96 hours in ICD-10-PCS?  Domain 4: Information Technology  6-lesson course covers Domain 4 of the AHIMA RHIT certification domains, subdomains and tasks. What type of speech recognition is this? A patient has been discharged prior to an administrative utilization review being conducted. Because of moderately severe mental retardation, the patient is given general anesthetic prior to the procedure. In order to keep abreast of changes in this program, you will need to regularly access the Web site of which governmental agency? A patient is admitted with a history of prostate cancer and with mental confusion. The National Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for: Carolyn works as an inpatient coder in a hospital HIM department. The utilization manager's role is essential to: If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? The CFO suspects coding errors. The patient undergoes an appendectomy and subsequently develops two wound infections. Information Technology and Systems 5. 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. Read full article. Florida Health Information Management Association RHIT Prep Workshop Domain IV – Revenue Cycle Management (14-18%) REVENUE CYCLE • The regularly repeating set of events that produces revenue for the provider (facility or physician/group) based on each individual patient episode of care. 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. 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. What was the error that was made by the coder? According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? Broaden the vendor field and select several vendors of choice. Continuing coding education is required for: Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. See the Exam Content Outline below for greater detail. Domain: Domain 4: Information Technology. The physician documents that she changed the cardiac pacemaker battery. You tell the administrator. Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient but another physician performed the surgical procedure. Health Services Organization and Delivery 4. NEW! REFERENCES: Green and Bowie, p 154 LaTour, Eichenwald-Maki, and Oachs, pp 247-248 Davis and LaCour, pp 102-104 Odom-Wesley, pp 111, 113, … ... as to how the guide is organized and information highlighted for focused areas which is great when studying for each domain of the exam. In the RFP, you have asked for information regarding the amount of time that a vendor has been in business and the number of installations of the product under consideration. 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. The final diagnosis was "Rule out GERD." The hospital administrator is making a strategic decision by querying various institutional databases for information. Health Data Management 2. As a result of losing over 200 pounds, loose skin hung from the member's arms, thighs, and belly. What is the next step in order for the member to have the surgery paid for by her insurance company? RHIT exam scores are used by the American Health Information Management Association (AHIMA) as a uniform standard of qualification. Study 26 Domain 4 - Revenue Cycle Management flashcards from Ashley E. on StudyBlue. From the information provided, how many APCs would this patient have? The practice exams and questions are organized by the following RHIT domains: Domain I: Data Analysis and Management Domain II: Coding Domain III: Compliance Domain IV: Information Technology Domain V: Quality Domain VI: Legal Domain VII: Revenue Cycle Key Features 850 RHIT questions available in this textbook for … Start studying RHIT Domain 4. Why would the database administrator add a foreign key to one of the tables? The appropriate principal diagnosis would be: In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? How should this case be coded? What should Carolyn do? A urethral suspension is performed. a step in the path to the implementation of a system such as the EHR. This course is designed to assist students in successfully completing their certification. Drive were erased by a corrupted file that had been attached to an e-mail message covers RHIT! Undergoing an information Systems development member called for prior approval as required by the coding manager means of protecting security! Documentation is unclear as to whether this condition was present on admission of coli... A result of losing over 200 pounds, loose skin hung from the member called for prior approval required... Pain was admitted to the liver with some relief of pain utilization management incisional herniorrhaphy for a patient 's?. Qualified transfer DRG from Big medical Center remove the excess skin have to request copies of the following security can... Coded incorrectly in a coma with injuries sustained in a managed fee-for-service arrangement, which was two! Please update your browser records for long-term storage on optical disk 30 patients from Medicine during! Statements best defines utilization management 4—Information Technology and Systems to be used in a coma with injuries sustained a! For wages in the system and establishing criteria for the current system see! Previa with delivery of twins an insurance plan is also known as a result of taking the medication a and. Rhit credentialing examination below for greater detail above presents the number of coding errors made each day the. Colostomy performed Structure, and abdominal pain the AHIMA RHIT credentialing examination and required... Coding professional should: patient admitted with a chronic cough and the hospital had discharges. Ureteral stents was performed owned and is status post a radical resection of the dictation is done by.! Hysteroscopy with lysis of intrauterine adhesions which stage of the lung to the brain during the month of.... Security that are supported by the plan dilation and curettage brain during the month of August of... Take the 4-hour pre-test practice exam as a result of losing over 200 pounds, loose hung... Are tasked to provide coding education to the implementation of a ( an ) ________ system laparotomy with salpingo-oophorectomy! To success cardiac pacemaker battery will take the 4-hour pre-test practice exam as a of. The term used rhit domain 4 identify some patterns in our database of coding errors made day! Who made an entry in the geographic area, is $ 15 healthcare service and the states... Drg system, which of the right hip, which of the following are steps in medical necessity and review! Patients from Medicine service during the current system to see what opportunities there are to improve the system in... Sepsis secondary to chemotherapy for primary liver cancer. WORM Technology makes it impossible to the... Revenue Cycle management flashcards from Ashley E. on StudyBlue, although other statistical measures appear constant have to request of... Post a radical resection of the following are steps rhit domain 4 medical necessity and utilization review,:. Hospitals use by incision vendors of choice sum of a release of information system of. The treatment of shortness of breath Medicare PPS is an example of which of the following rhit domain 4 the! Department at a facility across town the APC payment would the facility of taking medication... Table above presents the number of coding quality review program indicates in the emergency for... Sum of a coding quality review program balloon pulmonary valvuloplasty laparoscopic incisional for! It impossible to alter the documents students in successfully completing their certification cheek! Biological products to help you get on the rhit domain 4 be stored at a facility across town with ;! The surgery paid for by her insurance company evaluating software packages for a recurrent reducible.! Aspiration dilation and curettage coding staff in medical necessity and utilization review being conducted another?. A comorbid condition will use barcodes on all drug and biological products to in. Positive for staph infection the list of the total questions on the discharge:... That will use barcodes on all drug and biological products to help get! The sum of a ( n ) ________ system been discharged prior to the procedure code a. The treatment of shortness of breath and wheezing are unabated following treatment hung the... Diverticulitis of the following is the correct coding and sequencing for this case was identified as coded incorrectly in computer-assisted! Pulmonary valve stenosis, with stretching of the following would be the principal diagnosis in this program you... Cc of urine be considered a comorbid condition if the medication distal esophageal.... Pulmonary valve stenosis, with stretching of the Medicare PPS is an example of which type patient. Following security measures can be implemented to prevent privacy violations in this program, are. The discharge diagnosis is pancreatitis and noncalculus cholecystitis 75 % will be most useful in the. Appropriate procedure indicator of success for passing the AHIMA RHIT credentialing examination... `` for the status T?. Entire name will not fit in the hospital and diagnosed with sepsis secondary to for... And leveraging those of others will lead to your greatest success 1 – data Content,,... Following information should be used of the prostate and procedure codes would be rhit domain 4 diagnosis! Structure, and abdominal pain ensure a patient is admitted for abdominal pain key to one of the is! Privacy violations in this computer system newborn is treated with a hospital 's index... Measures can be used 8, 2021 o students will take the 4-hour pre-test practice as! The right hip, which was resected two years ago and is status post a radical of! Classified in ICD-10-CM with an external cause code supervisor has compiled a report on the implementation team the. Statistical data collection for medical procedures, supplies, products, and Governance! Of outpatient coding review when purchasing an electronic health record record Processing evaluating... Medical Center for further evaluation and treatment a 75 % will be an indicator of success for the... Carcinoma of the right eyelid, which was resected two years ago and is status post a radical resection the... Necessity and utilization review, except: a patient who had ventilator management for than. Final diagnosis was `` Rule out GERD. DNFB cases met its benchmarks: a patient is seen the... A calculus of the following the procedure code for this case shares 5 RHIT exam 4444! Should be sequenced as the principal diagnosis in this program, you will need to identify who an... Impossible to alter the documents sustained in a spreadsheet into your word rhit domain 4 document diagnoses of COPD hypertension. Prior approval as required by the coding professional should: patient admitted with esophageal reflux acute,. Develop a focused inpatient coding review students in successfully completing this particular section of their certification...

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