AHIMA RHIT Practice Test

Answer choices

1. A. Delete the attending diagnosis because another clinician disagreed.
2. B. Keep every conflicting diagnosis and let the grouper decide.
3. C. Use a nonleading query to clarify the conflicting documentation before finalizing the coded data when clarification is needed.
4. D. Choose the diagnosis that produces the lower payment to avoid audit risk, with the decision documented before routine claim submission.

Wrong-answer review

• A. Delete the attending diagnosis because another clinician disagreed.: Incorrect. HIM staff should not independently erase a provider diagnosis based on disagreement.
• B. Keep every conflicting diagnosis and let the grouper decide.: Incorrect. The record should be clarified when provider documentation conflicts materially.
• D. Choose the diagnosis that produces the lower payment to avoid audit risk, with the decision documented before routine claim submission.: Incorrect. Coding should reflect clarified documentation, not payment conservatism. The additional workflow detail does not change why this option is substantively incorrect.

Answer choices

1. A. An overlay, because a duplicate always combines two patients in one record.
2. B. A breach by definition, because every legal name change is an unauthorized disclosure.
3. C. A harmless alias that requires no correction.
4. D. A duplicate record that can fragment history and should be resolved through the organization’s MPI process.

Answer choices

1. A. Keep billing and plan to fix the encoder at year-end.
2. B. Backdate October encounters into September so old codes remain valid, with this approach applied consistently across comparable compliance findings.
3. C. Delete the encoder audit log after installing the update.
4. D. Contain affected claims, update the encoder, retest, and identify whether any post-effective-date claims require correction.

Answer choices

1. A. Patient right-of-access processing.
2. B. Medical-record retention scheduling.
3. C. Credential recertification for HIM staff, with this approach applied consistently to comparable claims.
4. D. Charge capture and the interface or workflow that transfers the charge to billing.

Answer choices

1. A. Access to PHI is limited to information needed for assigned duties; curiosity or convenience does not create authorization.
2. B. Volunteers may view any chart if they do not print or copy it, so comparable requests receive the same privacy treatment, with the action routed through the standard privacy review process.
3. C. Only paid employees are subject to workforce privacy expectations.
4. D. Diagnosis access is acceptable if the patient is currently in the building.

Answer choices

1. A. Leave the paper forms unchanged because they are used only during downtime, under the existing data-governance process for similar cases.
2. B. Remove all paper backups so only the EHR can be used.
3. C. Update and replace the controlled paper backups at the same time as the electronic template change.
4. D. Tell staff to handwrite the missing field whenever they remember.

Answer choices

1. A. Follow the approved duplicate-resolution process to merge or link the records with a complete audit trail.
2. B. Delete the older record so only the current name remains.
3. C. Merge every record with a similar name to prevent future duplicates.
4. D. Leave both records permanently separated because merging always creates privacy risk.

Answer choices

1. A. Have the HIM policy owner revise the procedure independently, then circulate the final version to nursing and IT after approval to avoid slowing the revision process.
2. B. Only IT, because the procedure involves the EHR.
3. C. No operational staff, because executives can infer the workflow.
4. D. Representatives from the affected functions, with an accountable policy owner and required compliance or legal review as appropriate.

Answer choices

1. A. Teach that uncertain diagnoses are never coded in any setting.
2. B. Teach coders to code whichever condition is most likely clinically.
3. C. Avoid discussing the error because education could influence future coding, so staff apply one consistent approach to similar claims.
4. D. Use focused examples contrasting outpatient and inpatient uncertain-diagnosis rules and verify understanding afterward.

Answer choices

1. A. Radiology findings can always replace the treating provider’s diagnosis for coding purposes.
2. B. The coder should select whichever diagnosis produces the highest-weighted payment group.
3. C. Code assignment is generally based on the provider’s diagnostic statement, so clarification may be needed when the diagnosis lacks required specificity.
4. D. The coder should ignore all non-provider documentation even when the official guidelines permit exceptions, with the same process used for comparable documentation issues.