AHIMA RHIT (Registered Health Information Technician) — All Questions

A facility's master patient index (MPI) shows that one patient has been assigned two different medical record numbers within the same hospital. This error is best described as:

• a.An overlay
• b.An overlap
• c.A duplicate✓
• d.A merge

A duplicate exists when one patient is assigned two or more medical record numbers within the same facility, so the patient has two separate records. An overlay is the opposite and more dangerous error: two different patients share one medical record number, mixing their data. An overlap is one patient having different numbers across facilities in an enterprise MPI. A merge is the corrective action, not the error. MPI integrity is central to patient safety and data governance.

In the AHIMA data quality management model, the characteristic describing data that reflects the correct, true value is:

• a.Accuracy✓
• b.Completeness
• c.Timeliness
• d.Granularity

Accuracy means the data is correct and reflects the true value being captured. Completeness means all required data is present, timeliness means the data is recorded and available when needed, and granularity refers to the level of detail. These are distinct characteristics in the AHIMA data quality model, and the RHIT must be able to separate them because improvement efforts differ for each.

Under the Medicare Conditions of Participation and Joint Commission standards, a history and physical (H&P) for an inpatient must be documented:

• a.Within 24 hours of admission✓
• b.Within 48 hours of admission
• c.Within 72 hours of admission
• d.Within 7 days of admission

CMS Conditions of Participation and Joint Commission require the H&P to be completed and placed in the record within 24 hours of inpatient admission (and before surgery). An H&P completed within 30 days prior to admission may be used if an updated note confirms no changes. Monitoring H&P timeliness is a core HIM record-completion function.

In a problem-oriented medical record (POMR), progress notes are most commonly documented using which structured format?

• a.SOAP (Subjective, Objective, Assessment, Plan)✓
• b.SBAR (Situation, Background, Assessment, Recommendation)
• c.A source-oriented narrative grouped by department
• d.A flowsheet of vital signs only

The problem-oriented medical record uses SOAP notes — Subjective (patient statements), Objective (measurable findings), Assessment (diagnosis/impression), and Plan (treatment) — each tied to a numbered problem list. SBAR is a communication/hand-off tool, not a charting format. A source-oriented record organizes by department rather than by problem. Recognizing record formats is fundamental to record content and structure.

A nurse transcribes a verbal order given by a physician during an emergency. To properly authenticate that order, the ordering provider must:

• a.Date, time, and sign (countersign) the order within the timeframe set by CMS and facility policy✓
• b.Do nothing, because the nurse's signature makes it valid
• c.Write a new order at the patient's next admission
• d.Have the pharmacist co-sign it instead

Authentication of a verbal order requires the responsible provider to date, time, and sign it within the timeframe defined by CMS Conditions of Participation, state law, and facility policy. The nurse's transcription documents the order but does not authenticate it. Verbal orders should be limited to true necessity, and HIM monitors timely provider countersignature as part of documentation compliance.

A hospital is setting the retention period for the health record of a pediatric patient. The retention clock should generally run:

• a.Until the patient reaches the age of majority plus the applicable state statute of limitations✓
• b.Exactly five years from the date of the visit, then destroy
• c.Only until the patient is discharged
• d.For 30 days after the encounter

For minors, retention typically extends until the patient reaches the age of majority plus the state's statute of limitations, because the legal clock for a minor to bring an action does not begin until adulthood. Facilities follow the longest applicable requirement among state law, Medicare, and accreditation standards. A fixed short period would expose the facility to legal risk for records of minors.

A hospital discharged 500 patients during the month, and 15 of those patients died before discharge. The gross death (mortality) rate for the month is:

• a.1.5%
• b.3%✓
• c.5%
• d.30%

Gross death rate = (number of inpatient deaths ÷ number of discharges, including deaths) × 100. Here 15 ÷ 500 = 0.03, or 3%. The gross death rate counts all inpatient deaths, whereas the net death rate excludes deaths occurring within 48 hours of admission. Accurate rate computation is a core HIM statistics skill.

The case-mix index (CMI) for a hospital is calculated by:

• a.Summing the MS-DRG relative weights for all discharges and dividing by the number of discharges✓
• b.Dividing total charges by the number of patient days
• c.Counting the number of CCs and MCCs coded
• d.Averaging the length of stay across all patients

CMI is the average MS-DRG relative weight: sum the relative weights of all discharged cases and divide by the number of discharges. A higher CMI indicates a more resource-intensive, higher-severity patient population and generally higher reimbursement. CMI is used to monitor coding, documentation, and the financial profile of the patient mix.

An HIM analyst wants to display how the hospital's surgical-site infection rate changed month-to-month over a one-year period. The most appropriate graph is a:

• a.Pie chart
• b.Line graph✓
• c.Bar chart of a single total
• d.Frequency histogram of patient ages

A line graph is the best choice for showing a trend of a variable over time, because the connected points make increases and decreases across months easy to see. A pie chart shows parts of a whole at one point in time, and a histogram shows the distribution of a continuous variable. Matching the display to the message is a key data-presentation competency.

During the month, 300 patients were discharged and the total length of stay (discharge days) for all of them was 1,200 days. The average length of stay (ALOS) is:

• a.3 days
• b.4 days✓
• c.5 days
• d.12 days

ALOS = total length of stay (discharge days) ÷ number of discharges = 1,200 ÷ 300 = 4 days. Note that ALOS uses discharges, not admissions, and the median LOS may be reported instead when outliers skew the mean. Length-of-stay statistics support utilization review and benchmarking.

Under the Medicare Inpatient Prospective Payment System (IPPS), the payment for an inpatient stay is primarily determined by:

• a.The MS-DRG derived from the principal diagnosis, secondary diagnoses (CC/MCC), and procedures✓
• b.The number of days the patient stayed, billed per diem
• c.The chargemaster total of all itemized services
• d.The physician's professional fee schedule

IPPS pays a predetermined amount based on the MS-DRG, which is assigned from the principal diagnosis, the presence of complications/comorbidities (CC) or major CC (MCC), and significant procedures. Because payment is fixed per DRG regardless of actual charges, accurate coding and complete documentation directly drive appropriate reimbursement. Per-diem and charge-based methods apply to other payment systems, not inpatient IPPS.

A clinical documentation integrity (CDI) specialist needs clarification because the record shows clinical signs of a condition that is not clearly documented. A compliant physician query should:

• a.Present the relevant clinical indicators and remain non-leading✓
• b.Suggest the specific diagnosis that yields the highest payment
• c.Instruct the physician to document sepsis to raise the DRG
• d.Be sent only when it will increase the reimbursement

A compliant query is non-leading: it states the clinical indicators found in the record (labs, vitals, treatments) and asks the provider to clarify, without suggesting a specific answer or being driven by reimbursement. Leading queries or queries generated only when they raise revenue violate AHIMA/ACDIS query-practice standards and can constitute fraud. The goal is accurate documentation, not a higher DRG.

The hospital's chargemaster (charge description master, CDM) links each billable service to its:

• a.CPT/HCPCS code, revenue code, and charge amount✓
• b.Patient insurance premium and deductible
• c.ICD-10-CM principal diagnosis only
• d.Admitting physician's NPI schedule

The chargemaster is the master file that connects each chargeable item or service to its CPT/HCPCS code, revenue code, department, description, and price. Errors in the CDM propagate to every claim, so it must be maintained and audited regularly. Diagnoses (ICD-10-CM) are assigned by coders based on documentation, not stored in the chargemaster.

A Medicare outpatient service is likely to be denied as not medically necessary. Before providing it, the facility should have the patient sign a(n):

• a.Advance Beneficiary Notice of Noncoverage (ABN)✓
• b.Authorization to release information
• c.Notice of Privacy Practices
• d.General consent to treat

An Advance Beneficiary Notice (ABN) informs a Medicare beneficiary in advance that a service may not be covered and that they may be financially responsible, giving them the choice to proceed and pay. Without a valid ABN, the provider generally cannot bill the patient for a denied non-covered service. The other documents serve privacy and consent purposes, not financial-liability notice.

A coder is pressured by a supervisor to assign a higher-paying DRG that is not supported by the documentation. Knowingly submitting such a claim to Medicare violates the:

• a.Anti-Kickback Statute only
• b.False Claims Act✓
• c.EMTALA
• d.Stark Law only

Knowingly submitting, or causing the submission of, false or fraudulent claims to a federal program violates the False Claims Act, which also allows whistleblower (qui tam) suits and treble damages. Upcoding for unsupported reimbursement is a classic example. The Anti-Kickback Statute and Stark Law address referral/financial-relationship abuses, and EMTALA addresses emergency treatment obligations — different laws, different conduct.

The primary role of Medicare Recovery Audit Contractors (RACs) is to:

• a.Provide free legal defense to hospitals
• b.Detect and correct improper Medicare payments, including both overpayments and underpayments✓
• c.Set the relative values assigned to CPT codes
• d.Accredit hospitals for participation

RACs review Medicare claims after payment to identify improper payments — recovering overpayments and, less often, flagging underpayments. HIM staff support RAC responses by producing records and tracking appeals. Accreditation is performed by bodies such as the Joint Commission, and code values are set through CMS/AMA processes, not by RACs.

The Office of Inspector General (OIG) framework for an effective corporate compliance program is built around how many core elements?

• a.Three
• b.Five
• c.Seven✓
• d.Ten

The OIG describes seven elements of an effective compliance program: written standards/policies, a designated compliance officer/committee, effective training and education, open lines of communication, internal monitoring and auditing, enforcement through disciplinary guidelines, and prompt response and corrective action. These seven elements are a frequent RHIT exam topic and the backbone of healthcare compliance.

The HIPAA 'minimum necessary' standard applies to most uses and disclosures of PHI, but it does NOT apply to:

• a.Disclosures to a health care provider for treatment✓
• b.Disclosures to a business associate
• c.Internal uses for health care operations
• d.Disclosures to a health plan for payment

The minimum necessary standard requires limiting PHI to the least amount needed, but it expressly does not apply to disclosures to or requests by a provider for treatment, because full information is needed for safe patient care. It also does not apply to disclosures to the individual, uses required by law, or those authorized by the patient. Payment and operations uses are still subject to minimum necessary.

Under the HIPAA Privacy Rule, a patient's written authorization is generally NOT required to use or disclose PHI for:

• a.Treatment, payment, and health care operations (TPO)✓
• b.Marketing communications paid for by a third party
• c.The sale of PHI
• d.Most research uses without a waiver

The Privacy Rule permits use and disclosure of PHI for treatment, payment, and health care operations (TPO) without patient authorization. Marketing that is paid for by a third party, the sale of PHI, and most research disclosures do require a valid authorization (or an IRB/Privacy Board waiver for research). Knowing what falls inside TPO is essential to correct release-of-information decisions.

Under the HITECH breach notification requirements, affected individuals must be notified of a breach of unsecured PHI without unreasonable delay and no later than:

• a.30 days after discovery
• b.60 days after discovery✓
• c.90 days after discovery
• d.180 days after discovery

The Breach Notification Rule requires notifying affected individuals without unreasonable delay and no later than 60 calendar days after discovery of the breach. Breaches affecting 500 or more individuals also require prompt notice to HHS and to prominent media in the affected area; smaller breaches are logged and reported to HHS annually. HIM often coordinates breach response.

When calculating staffing needs, one full-time equivalent (FTE) employee is generally considered equal to how many paid hours per year?

• a.1,040
• b.1,560
• c.2,080✓
• d.2,600

One FTE equals 2,080 paid hours per year (40 hours/week × 52 weeks). Managers convert workload and productivity data into FTE requirements to justify staffing. Note that productive hours are lower than 2,080 once paid time off, holidays, and orientation are subtracted, which is why productive-hour adjustments matter in real scheduling.

A performance-improvement team is using the PDSA cycle. In this model, the 'S' stands for:

• a.Standardize
• b.Study✓
• c.Sustain
• d.Schedule

PDSA stands for Plan–Do–Study–Act, a rapid-cycle improvement method: plan a change, do a small test, study the results against the prediction, and act to adopt, adapt, or abandon the change. 'Study' emphasizes analyzing outcome data before spreading the change. PDSA is one of the most widely used quality-improvement frameworks in healthcare.

A document that gives detailed, step-by-step instructions for how staff should complete a specific task is best classified as a:

• a.Policy
• b.Procedure✓
• c.Bylaw
• d.Mission statement

A procedure specifies the step-by-step 'how' of accomplishing a task, whereas a policy states the organization's overall 'what' and 'why' — the rule or principle. Bylaws govern organizational structure (for example, medical staff bylaws), and a mission statement expresses purpose. Distinguishing policies from procedures is a basic management competency for HIM leaders.