RHIA Domain 4 Practice Exam Questions
and Answers All Correct
The process in which a healthcare entity addresses the provider documentation issues
of legibility, completeness, clarity, consistency, and precision is called:
a. Query process
b. Release of information process
c. Coding process
d. Case-finding process - Answer-A
Healthcare entities should consider a policy in which queries may be appropriate when
documentation in the patient record fails to meet one of the following five criteria:
legibility, completeness, clarity, consistency, and precision (Hunt and Kirk 2020, 285-
287).
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw
300 patients, so he received $4,500 from the health plan. What method is the health
plan using to reimburse Dr. Tan?
a. Traditional retrospective
b. Capitated rate
c. Relative value
d. Discounted fee schedule - Answer-B
Capitated rate is a method of payment for health services in which the third-party payer
reimburses providers a fixed, per capita amount for a period. Per capita means per
head or per person. A common phrase in capitated contracts is per member per month
(PMPM). The PMPM is the amount of money paid each month for each individual
enrolled in the health insurance plan. Capitation is characteristic of HMOs (Casto 2018,
9-10).
Community Hospital has received a large number of claims denials for CT scans that
were provided to patients. After review of the denied claims, the hospital has
determined that clinical indications for the CT scan were not present. For which of the
following reasons were these claims denied for payment?
a. Patient preferences were ignored.
b. These scans did not meet medical necessity.
c. No order was present in the record for the scans.
d. Best practices for billing were not used. - Answer-B
The increased awareness of duplication of services increased the drive to determine the
medical necessity for treatments and care. Purchasers and payers of healthcare
services began to demand a more comprehensive approach to care—one that
decreased costs and improved the quality of care provided. Along with this demand
,came standards intended to ensure that the services provided were timely, cost-
efficient, and appropriate to the patient's medical condition. As patients were stuck with
medical bills that insurance companies refused to pay and providers were unwilling to
write off because they were not deemed medically necessary, new processes were
developed to address these concerns (Shaw and Carter 2019, 134).
Using the information provided, if the physician is a non-PAR who accepts assignment,
how much can he or she expect to be reimbursed by Medicare?
Physician's normal charge = $340
Medicare Fee Schedule = $300
Patient has met his deductible
a. $228
b. $240
c. $285
d. $300 - Answer-A
Nonparticipating providers (nonPARs) do not sign a participation agreement with
Medicare but may or may not accept assignment. If the nonPAR physician elects to
accept assignment, he or she is paid 95 percent (5 percent less than participating
physicians) of the Medicare fee schedule (MFS). For example, if the MFS amount is
$200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider
receives only $152 (95 percent of $160). In this case the physician is nonparticipating
so he or she will receive 95 percent of the 80 percent of the MFS or 80 percent of 300,
which is $240; 95 percent of the $240 is $228 (Casto 2018, 144, 320-321).
Which of the following is not a reason to deliver a hospital-issued notice of noncoverage
(HINN) to a Medicare beneficiary?
a. Service is not medically necessary
b. Service was not preauthorized
c. Service was not delivered in the most appropriate setting
d. Service is custodial in nature - Answer-B
Absence of preauthorization is not a reason for issuing a hospital-issued notice of
noncoverage (Handlon 2020, 248).
Which of the following healthcare entities' mission is to reduce Medicare improper
payments through detection and collection of overpayments, identification of
underpayments, and implementation of actions that will prevent future improper
payments?
a. Accountable care entity
b. Managed care entity
c. Revenue reduction contractor
d. Recovery audit contractor - Answer-D
,Recovery audit contractors (RACs) carry out the provisions of the National Recovery
Audit Program. RACs work with a mission of reducing Medicare improper payments
through detection and collection of overpayments, identification of underpayments, and
implementation of actions that will prevent future improper payments (Casto 2018, 39-
42).
In the Hospital Value-Based Purchasing Program, a facility's total performance score
(TPS) is used to determine the amount of holdback dollars the facility has earned. In
regard to the TPS, which is better?
a. A higher TPS is better.
b. A lower TPS is better.
c. A consistent TPS is better.
d. A downward trend in TPS is better. - Answer-A
The hospital value-based purchasing (VBP) will measure hospital performance using
four domains. The domain scores are combined resulting in a total performance score
(TPS). A facility's TPS determines what portion of the hold back amount the facility will
earn back. For every point increase in the TPS, the provider will increase payment by a
portion of the hold back dollars, so in this VBP, the higher TPS score is desired (Casto
2018, 293-294).
A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with
ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia.
The operative site is closed without the repair of the hernia. What is the correct code
assignment?
I97.191 Other postprocedural cardiac functional disturbances following other surgery
K43.9 Ventral hernia without obstruction or gangrene
R00.1 Bradycardia, unspecified
Z53.09 Procedure and treatment not carried out because of other contraindication
Section Body Root Body Part Approach Device Qualifier
System Operation
Medical/ Anat. Reg. Inspection Perit. Cav. Open No No
Surgical General Device Qualifier
0WJG0ZZ
Section Body Root Body Part Approach Device Qualifier
System Operation
Medical/ Anat. Reg. Repair Abd. Wall Open No No
Surgical General Device Qualifier
0WQF0ZZ
a. K43.9, R00.1, Z53.09, 0WJG0ZZ
b. K43.9, I97.191, R00. - Answer-A
, The repair of the hernia is not coded because it was not performed; however, code
0WJG0ZZ is assigned to describe the extent of the procedure, inspection of the
peritoneal cavity based on ICD-10-PCS Guideline B3.3. The Z53.09 is also used to
indicate the cancelled procedure due to the contraindication. The code R00.1 is also
added for the bradycardia that the patient developed during the procedure (Kuehn and
Jorwic 2020, 41-42; Schraffenberger and Palkie 2020, 689).
When attempting to build patient relations and customer service in the revenue cycle
related to the patient's financial obligations, providers should focus which of the
following approaches?
a. Consumer-centric approach
b. Patient engagement approach
c. Transparency approach
d. Payment variance approach - Answer-C
Hospital-issued notices of noncoverage (HINNs) can be issued at any of the following
times except:
a. Prior to admission
b. At admission
c. At any point during the hospital stay
d. After discharge - Answer-D
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. However, the physician's documentation is unclear
as to whether this condition was present on admission. How should the clinical
documentation specialist proceed?
a. Note the condition as present on admission
b. Query the physician to determine if the condition was present on admission
c. Note the condition as unknown on admission
d. Note the condition as not present on admission - Answer-B
Under RBRVS, which elements are used to calculate a Medicare payment?
a. Work value and extent of the physical exam
b. Malpractice expenses and detail of the patient history
c. Work value and practice expenses
d. Practice expenses and review of systems - Answer-C
The facility's Medicare case-mix index has dropped, although other statistical measures
appear constant. The CFO suspects coding errors. What type of coding audit review
should be performed?
a. Random audit
b. Focused audit
c. Compliance audit
d. External audit - Answer-B
