Nadia Fourie is admitted to Lakeshore Regional Hospital for an elective hip replacement. Her history and physical (H&P) was completed in the orthopedic surgeon's office 20 days before admission. What does the Medicare Conditions of Participation require before surgery?

An update note documenting any changes, completed within 24 hours after admission and before surgery

A countersignature of the office H&P by the hospitalist within 48 hours after the surgery

Nothing further, because an H&P completed within 30 days of admission is acceptable as written

A completely new H&P, because an office H&P cannot be used for an inpatient admission

The mother of 15-year-old Diego Alvarez asks the clinic for full access to his patient portal account, including messages. Under the clinic's policy, which follows state law, adolescents may consent to certain confidential services. What should the HIM technician do?

Set up proxy access with the adolescent limits the portal policy sets under state minor-consent law

Deny all proxy access until Diego turns 18, because adolescent records can never be shared with parents

Give the mother Diego's own username and password so that she can see everything in the account

Grant full proxy access, because parents are always the personal representative of minor children

Malik Johnson, an established patient at Brightwater Primary Care, comes in for a scheduled excision of a small skin lesion. During the visit he also reports worsening asthma, and the physician performs and documents a separate history, exam and medication change for it. Which modifier should be appended to the office E/M code?

-25, for a significant, separately identifiable E/M service on the same day

-51, for multiple procedures performed by the same physician on one day

-59, for a distinct procedural service performed during the same encounter

-79, for an unrelated procedure performed during a postoperative period

Lakeside Medical Center outsources release of information to a copy vendor. The hospital's quarterly audit of 50 vendor releases finds 3 packets that included dates of service outside the scope of the patient's authorization. What should the HIM director do?

Assess each release for a breach, require a corrective action plan and increase auditing

Take no action, because the vendor is a business associate and answers for its own errors

Report all 50 audited releases to the Office for Civil Rights as breaches within 60 days

End the vendor contract at once and bring all release work in-house without further review

A hospital that participates in Medicare is setting its record completion policy. Under the Conditions of Participation, what is the latest point at which an inpatient record must be completed?

Before the claim is submitted to the payer

Within 48 hours after discharge

Under its retention schedule, Maple Hill Hospital is destroying inpatient records from discharges more than 25 years ago, as state law allows. What should happen to the master patient index (MPI) entries for those patients?

Keep the MPI entries permanently

Keep them for six more years only

Delete them along with the records

Ten days after a knee arthroscopy with a 90-day global period, Owen Fitzgerald returns to the same surgeon at Lakeshore Orthopedics, who removes a suspicious mole from his back. Which modifier should be appended to the mole removal code?

-79, unrelated procedure by the same physician during the postoperative period

-25, significant, separately identifiable E/M service on the day of a procedure

-76, repeat procedure by the same physician on the same day as the original

-26, professional component reported separately from the technical component

RHIT Exam

Free RHIT Practice Questions

10 sample questions for the RHIT Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Health Record Content, Documentation Standards and Record Completion, Information Governance, EHR Systems, Data Standards and the MPI, Privacy, Release of Information and Patient Rights, Healthcare Data Sources, Statistics and Reporting, Coding Systems, Coding Guidelines and Clinical Documentation Integrity, Revenue Cycle, Reimbursement Methodologies and Payers, Leadership, Policies, Interoperability and Project Management.

Question 1 · Health Record Content, Documentation Standards and Record Completion
Nadia Fourie is admitted to Lakeshore Regional Hospital for an elective hip replacement. Her history and physical (H&P) was completed in the orthopedic surgeon's office 20 days before admission. What does the Medicare Conditions of Participation require before surgery?
- A.A countersignature of the office H&P by the hospitalist within 48 hours after the surgery
- B.Nothing further, because an H&P completed within 30 days of admission is acceptable as written
- C.An update note documenting any changes, completed within 24 hours after admission and before surgery
- D.A completely new H&P, because an office H&P cannot be used for an inpatient admission
Show answer and explanation
Answer: C. An update note documenting any changes, completed within 24 hours after admission and before surgery
Under the CoP, an H&P may be completed no more than 30 days before admission, but an update note documenting any changes in the patient's condition must be done within 24 hours after admission and before surgery. A brand-new H&P is not required, the 30-day H&P cannot be used without the update, and a post-surgery countersignature does not meet the before-surgery requirement.
Question 2 · Information Governance, EHR Systems, Data Standards and the MPI
The mother of 15-year-old Diego Alvarez asks the clinic for full access to his patient portal account, including messages. Under the clinic's policy, which follows state law, adolescents may consent to certain confidential services. What should the HIM technician do?
- A.Deny all proxy access until Diego turns 18, because adolescent records can never be shared with parents
- B.Give the mother Diego's own username and password so that she can see everything in the account
- C.Set up proxy access with the adolescent limits the portal policy sets under state minor-consent law
- D.Grant full proxy access, because parents are always the personal representative of minor children
Show answer and explanation
Answer: C. Set up proxy access with the adolescent limits the portal policy sets under state minor-consent law
Portal proxy access for adolescents is typically limited by age-based rules that protect information the minor may consent to under state law. Sharing the patient's own credentials defeats identity and audit controls, parents are not the personal representative for care the minor lawfully consented to, and a blanket denial ignores the parent's legitimate access to other information.
Question 3 · Healthcare Data Sources, Statistics and Reporting
Priya Nair was admitted to Lakeside Hospital on March 28 and discharged on April 3. What is her length of stay for statistical reporting?
- A.7 days
- B.4 days
- C.6 days
- D.5 days
Show answer and explanation
Answer: C. 6 days
Length of stay = discharge date minus admission date, counting the day of admission but not the day of discharge: March 28 to April 3 is 6 days (4 days in March, March 28 through 31, plus April 1 and 2). Counting both the admission and discharge days gives 7, and 5 or 4 days comes from miscounting the days left in March.
Question 4 · Coding Systems, Coding Guidelines and Clinical Documentation Integrity
Malik Johnson, an established patient at Brightwater Primary Care, comes in for a scheduled excision of a small skin lesion. During the visit he also reports worsening asthma, and the physician performs and documents a separate history, exam and medication change for it. Which modifier should be appended to the office E/M code?
- A.-51, for multiple procedures performed by the same physician on one day
- B.-25, for a significant, separately identifiable E/M service on the same day
- C.-59, for a distinct procedural service performed during the same encounter
- D.-79, for an unrelated procedure performed during a postoperative period
Show answer and explanation
Answer: B. -25, for a significant, separately identifiable E/M service on the same day
Modifier -25 is appended to an E/M code when the provider performs a significant, separately identifiable evaluation and management service on the same day as a procedure, which the asthma workup represents. Modifier -59 identifies distinct non-E/M procedures, -79 applies to procedures during a global period, and -51 flags multiple procedures. None of these describes a separate E/M service.
Question 5 · Revenue Cycle, Reimbursement Methodologies and Payers
Lakeside Medical Center outsources release of information to a copy vendor. The hospital's quarterly audit of 50 vendor releases finds 3 packets that included dates of service outside the scope of the patient's authorization. What should the HIM director do?
- A.Take no action, because the vendor is a business associate and answers for its own errors
- B.Assess each release for a breach, require a corrective action plan and increase auditing
- C.Report all 50 audited releases to the Office for Civil Rights as breaches within 60 days
- D.End the vendor contract at once and bring all release work in-house without further review
Show answer and explanation
Answer: B. Assess each release for a breach, require a corrective action plan and increase auditing
The covered entity remains responsible for overseeing its business associate. Each over-release is an impermissible disclosure that needs a documented four-factor risk assessment to decide whether notification is required, and the vendor should fix the cause under its business associate agreement and service-level agreement while the hospital audits more often. Treating the vendor as solely responsible ignores the hospital's oversight duty, reporting all 50 releases treats compliant releases as breaches, and ending the contract on the spot skips the breach analysis and corrective process.
Question 6 · Health Record Content, Documentation Standards and Record Completion
A hospital that participates in Medicare is setting its record completion policy. Under the Conditions of Participation, what is the latest point at which an inpatient record must be completed?
- A.Within 30 days after discharge
- B.Within 14 days after discharge
- C.Before the claim is submitted to the payer
- D.Within 48 hours after discharge
Show answer and explanation
Answer: A. Within 30 days after discharge
The Medicare CoP require inpatient records to be completed within 30 days following discharge. Medical staff bylaws may set shorter internal deadlines, but 14 days and 48 hours are not the federal limit, and claim submission is a billing event rather than a record completion standard.
Question 7 · Information Governance, EHR Systems, Data Standards and the MPI
Under its retention schedule, Maple Hill Hospital is destroying inpatient records from discharges more than 25 years ago, as state law allows. What should happen to the master patient index (MPI) entries for those patients?
- A.Keep them for six more years only
- B.Move them to the disease index
- C.Keep the MPI entries permanently
- D.Delete them along with the records
Show answer and explanation
Answer: C. Keep the MPI entries permanently
The MPI is a permanent record; keeping the entries shows that the patient was treated and that the record was destroyed under the retention schedule. Deleting the entries or keeping them for a set period would leave no evidence of past care, and the disease index serves a different purpose.
Question 8 · Healthcare Data Sources, Statistics and Reporting
The HIM technician at Kestrel Valley Critical Access Hospital listed the following discharges for one week.
Patient Admitted Discharged
Patient 1 Oct 2 Oct 5
Patient 2 Oct 4 Oct 4
Patient 3 Oct 6 Oct 11
Patient 4 Oct 9 Oct 11
Patient 5 Oct 10 Oct 16
Patient 6 Oct 12 Oct 12
Patient 7 Oct 13 Oct 17
What is the average length of stay for these discharges? Round to one decimal place.
- A.4.4 days
- B.2.9 days
- C.3.1 days
- D.3.9 days
Show answer and explanation
Answer: C. 3.1 days
Lengths of stay are 3, 1, 5, 2, 6, 1 and 4 days, because a patient admitted and discharged the same day counts as 1 day; the total is 22 days and 22 ÷ 7 = 3.1. Counting same-day stays as 0 gives 20 ÷ 7 = 2.9. Counting both the admission and discharge days gives 27 ÷ 7 = 3.9, and dividing 22 by only the 5 multi-day patients gives 4.4.
Question 9 · Coding Systems, Coding Guidelines and Clinical Documentation Integrity
Ten days after a knee arthroscopy with a 90-day global period, Owen Fitzgerald returns to the same surgeon at Lakeshore Orthopedics, who removes a suspicious mole from his back. Which modifier should be appended to the mole removal code?
- A.-25, significant, separately identifiable E/M service on the day of a procedure
- B.-76, repeat procedure by the same physician on the same day as the original
- C.-26, professional component reported separately from the technical component
- D.-79, unrelated procedure by the same physician during the postoperative period
Show answer and explanation
Answer: D. -79, unrelated procedure by the same physician during the postoperative period
Modifier -79 reports a procedure by the same physician during the postoperative global period that is unrelated to the original surgery, allowing payment outside the global package. Modifier -76 is for repeating the same procedure, -25 attaches to an E/M service rather than a procedure, and -26 separates the professional component of a service such as an imaging interpretation.
Question 10 · Revenue Cycle, Reimbursement Methodologies and Payers
The coding supervisor at Copper Creek Hospital audited each outpatient coder last quarter. The department's accuracy target is 95%.
Coder Records reviewed Records correct
Rivera 80 77
Okafor 64 60
Lindqvist 90 87
Tanaka 50 48
Which coder falls below the accuracy target? Round rates to one decimal place.
- A.Okafor, at 93.8%
- B.Rivera, at 96.3%
- C.Tanaka, at 96.0%
- D.Lindqvist, at 96.7%
Show answer and explanation
Answer: A. Okafor, at 93.8%
Accuracy = correct ÷ reviewed × 100: Okafor 60 ÷ 64 = 93.8%, which is below 95%. Rivera is 77 ÷ 80 = 96.3%, Lindqvist 87 ÷ 90 = 96.7% and Tanaka 48 ÷ 50 = 96.0%, all meeting the target even though Tanaka had the fewest records reviewed.

Patient	Admitted	Discharged
Patient 1	Oct 2	Oct 5
Patient 2	Oct 4	Oct 4
Patient 3	Oct 6	Oct 11
Patient 4	Oct 9	Oct 11
Patient 5	Oct 10	Oct 16
Patient 6	Oct 12	Oct 12
Patient 7	Oct 13	Oct 17

Coder	Records reviewed	Records correct
Rivera	80	77
Okafor	64	60
Lindqvist	90	87
Tanaka	50	48

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