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Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies Syllabus

The Medical Coding and Reimbursement Methodologies syllabus for Registered Health Information Administrator / Technician (RHIA / RHIT) in full: 4 chapters, 13 topics and 34 sub-topics, every one listed below, plus 54 Medical Coding and Reimbursement Methodologies flashcards with answers.

4Chapters
13Topics
34Sub-topics
54Flashcards

Medical Coding and Reimbursement Methodologies syllabus: all 4 chapters

Expand any chapter to see its topics and sub-topics.

  1. ICD-10-CM Diagnosis Coding

     3 topics
    • ICD-10-CM Structure and Conventions
      • Alphabetic Index and Tabular List
      • Code structure, placeholders, and 7th characters
      • Includes, excludes1/excludes2, and instructional notes
    • Official Coding Guidelines
      • Principal versus secondary diagnosis selection
      • Combination codes and manifestation coding
      • Signs, symptoms, and uncertain diagnoses
    • Coding by Body System and Condition
      • Neoplasms and infectious diseases
      • Pregnancy, perinatal, and external causes
      • Z codes and status conditions

  2. ICD-10-PCS Procedure Coding

     3 topics
    • PCS Structure and Character System
      • Seven-character code construction
      • Root operations and approaches
    • PCS Coding Guidelines
      • Body part and device selection
      • Multiple and discontinued procedures
    • Procedure Documentation Interpretation
      • Operative report analysis
      • Identifying objective of the procedure

  3. CPT and HCPCS Coding

     3 topics
    • CPT Category I, II, and III Codes
      • Evaluation and management coding
      • Surgery, radiology, pathology, and medicine sections
      • Modifiers and their application
    • HCPCS Level II Coding
      • Supplies, drugs, and durable medical equipment
      • National versus local coverage
    • Outpatient Coding Conventions
      • First-listed diagnosis rules
      • Coding from outpatient documentation

  4. Reimbursement Systems

     4 topics
    • Prospective Payment Systems
      • MS-DRGs and inpatient PPS
      • APCs and outpatient PPS
      • RBRVS and physician fee schedule
    • Payers and Coverage
      • Medicare parts A through D
      • Medicaid and commercial payers
      • Managed care and value-based payment
    • Revenue Cycle Management
      • Charge capture and chargemaster (CDM)
      • Claims, remittance, and denials management
      • Case mix index and reimbursement impact
    • Coding Compliance and Quality
      • Coding audits and accuracy review
      • Computer-assisted coding and NLP
      • Fraud, abuse, and the False Claims Act

Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies flashcards — 54 questions with answers

  1. What is the maximum number of characters in an ICD-10-CM code, and what is the structure of the first three positions?

    Up to 7 characters. The first character is always a letter, the second is numeric, characters 3-7 can be letters or numbers; a decimal point is placed after the third character (category).

  2. In ICD-10-CM, what is the function of the 7th character extension, and what placeholder is used to fill empty positions before it?

    The 7th character adds information such as episode of care (e.g., A=initial, D=subsequent, S=sequela). The placeholder 'X' fills empty character positions so the 7th character lands in the correct position.

  3. What is the difference between the ICD-10-CM conventions 'Excludes1' and 'Excludes2'?

    Excludes1 means 'NOT CODED HERE'—the two conditions can never be reported together. Excludes2 means 'NOT INCLUDED HERE'—the condition is separate, so both codes may be reported together if the patient has both.

  4. In ICD-10-CM, what do the conventions 'NEC' and 'NOS' indicate?

    NEC (Not Elsewhere Classifiable) means the code is used when the documentation is specific but no distinct code exists ('other specified'). NOS (Not Otherwise Specified) is the equivalent of 'unspecified'—documentation lacks detail.

  5. In the ICD-10-CM Alphabetic Index, what do brackets, parentheses, and the colon convention signify?

    Brackets [ ] enclose synonyms/explanatory phrases (in Tabular) or manifestation codes. Parentheses ( ) enclose nonessential modifiers that do not affect code assignment. A colon in the Tabular List indicates an incomplete term that needs a modifier to be assignable.

  6. What do the ICD-10-CM instructional notes 'Code first' and 'Use additional code' direct the coder to do?

    They identify etiology/manifestation sequencing: 'Code first' the underlying condition, then 'Use additional code' for the manifestation. The etiology code is sequenced first and the manifestation code second.

  7. Per ICD-10-CM Official Guidelines, when is a condition designated as the principal diagnosis for inpatient coding?

    The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.

  8. What is the ICD-10-CM guideline for coding signs and symptoms when a definitive diagnosis has been established?

    Signs/symptoms that are integral to (routinely associated with) a confirmed disease process are NOT coded separately. Symptoms that are NOT routinely associated with the disease should be coded additionally.

  9. Per the ICD-10-CM guideline on 'uncertain diagnoses,' how is a condition documented as 'probable,' 'suspected,' or 'rule out' handled in the inpatient vs. outpatient setting?

    Inpatient (short-term/acute): code the uncertain diagnosis as if it exists. Outpatient: do NOT code uncertain diagnoses—instead code the documented signs, symptoms, or test findings to the highest level of certainty.

  10. What is the ICD-10-CM definition and coding rule for 'sequela' (late effect)?

    A sequela is a residual condition produced after the acute phase of an illness/injury has ended (no time limit). Code the residual/current condition first, then the sequela code; the original acute injury is never coded with the sequela.

  11. In ICD-10-CM, how are 'combination codes' defined and when are they used?

    A combination code is a single code that classifies two diagnoses, a diagnosis with an associated manifestation, or a diagnosis with an associated complication. Use it when the classification provides it; do not assign multiple codes if a combination code fully describes the condition.

  12. In ICD-10-CM Chapter 2 (Neoplasms), how is the principal/first-listed diagnosis determined when treatment is directed at the malignancy itself?

    When treatment is directed at the malignancy, the malignancy is sequenced as the principal/first-listed diagnosis. (Exception: if the encounter is solely for chemotherapy, radiation, or immunotherapy, the Z51.- code is sequenced first.)

  13. What sequencing does ICD-10-CM require for diabetes mellitus with an associated condition (e.g., diabetic chronic kidney disease)?

    Diabetes codes (categories E08-E13) are combination codes that include the type, body system affected, and complication. Assign as many codes as needed to describe all complications; the diabetes code is sequenced first, followed by additional codes where instructed (e.g., the stage of CKD).

  14. In ICD-10-CM obstetric coding, which chapter codes take sequencing priority, and what does the 7th character on many Chapter 15 codes indicate?

    Chapter 15 (Pregnancy, Childbirth, and the Puerperium / O codes) take sequencing priority over codes from other chapters. The 7th character identifies the fetus to which the code applies in multiple gestations (e.g., 0=single, 1=fetus 1).

  15. How many characters are in every ICD-10-PCS code, and what value set may each character take?

    Every ICD-10-PCS code is exactly 7 characters. Each character can be one of 34 possible values: digits 0-9 and letters A-H, J-N, P-Z (the letters I and O are excluded to avoid confusion with 1 and 0).

  16. What does each of the 7 characters represent in an ICD-10-PCS code from the Medical and Surgical section?

    1: Section, 2: Body System, 3: Root Operation, 4: Body Part, 5: Approach, 6: Device, 7: Qualifier.

  17. In ICD-10-PCS, what value is the first character (Section) for the Medical and Surgical section, and name three other sections.

    Medical and Surgical = '0'. Others include: 1=Obstetrics, 2=Placement, 3=Administration, 4=Measurement and Monitoring, B=Imaging, F=Physical Rehabilitation, etc.

  18. Define the ICD-10-PCS root operations 'Excision' vs. 'Resection.'

    Excision = cutting out/off, without replacement, a PORTION of a body part. Resection = cutting out/off, without replacement, ALL of a body part. The key distinction is partial (Excision) vs. whole (Resection).

  19. In ICD-10-PCS, distinguish the root operations 'Bypass,' 'Dilation,' and 'Occlusion.'

    Bypass = altering the route of passage of contents of a tubular body part. Dilation = expanding an orifice or the lumen of a tubular body part. Occlusion = completely closing an orifice or the lumen of a tubular body part.

  20. What are the seven ICD-10-PCS approach values' general categories?

    Open; Percutaneous; Percutaneous Endoscopic; Via Natural or Artificial Opening; Via Natural or Artificial Opening Endoscopic; Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance; External.

Show the other 34 Medical Coding and Reimbursement Methodologies flashcards

  1. In ICD-10-PCS, what is required for a device to be coded in the 6th character?

    A device is coded only if it remains in/on the patient after the procedure is completed. Instruments used to perform the procedure are not coded as devices. If no device is used, the value 'Z' (No Device) is used.

  2. Per ICD-10-PCS Guideline B3.2, when are multiple procedures coded during the same operative episode?

    Multiple procedures are coded if: (1) the same root operation is performed on different body parts with distinct values; (2) the same root operation is repeated at different body sites; (3) multiple root operations with distinct objectives are performed on the same body part; or (4) the same root operation is performed via a different approach.

  3. In ICD-10-PCS, how is the body part coded when a procedure is performed on a tubular body part involving a portion (Guideline B4.1c / continuous structure)?

    For a procedure performed on a continuous tubular body part, the body part value coded is the one that specifies the most distal portion of the procedure site (or as the guidelines direct). General rule: code to the most specific body part value available for the site treated.

  4. In ICD-10-PCS, what is the difference between the root operations 'Inspection' and 'Drainage'?

    Inspection = visually and/or manually exploring a body part. Drainage = taking or letting out fluids and/or gases from a body part. If a diagnostic drainage is for fluid sampling, the qualifier 'X' (Diagnostic) is used.

  5. When converting a physician's procedure documentation to ICD-10-PCS, what must the coder identify if the documented term doesn't match a PCS root operation?

    The coder must determine the objective of the procedure (what the physician actually did) and select the root operation based on its definition—not on the eponym or term the physician used. If documentation is insufficient, query the provider.

  6. In procedure documentation, what is the difference between a 'diagnostic' and a 'therapeutic' procedure, and how does it affect ICD-10-PCS coding?

    A diagnostic procedure is performed to obtain a sample/finding for diagnosis (often coded with the Diagnostic qualifier 'X' in PCS); a therapeutic procedure treats a condition. The intent/objective changes the root operation and/or qualifier selected.

  7. What are the three categories of CPT codes and the purpose of each?

    Category I: standard procedures/services (5-digit numeric, e.g., 99213). Category II: optional supplemental tracking codes for performance measurement (4 digits + 'F'). Category III: temporary codes for emerging/new technology and procedures (4 digits + 'T').

  8. How are CPT Category I codes organized into sections, and what is the numeric range concept?

    Six sections: Evaluation & Management (99202-99499), Anesthesia (00100-01999), Surgery (10004-69990), Radiology (70010-79999), Pathology & Laboratory (80047-89398), and Medicine (90281-99607). E/M is listed first despite not being numerically first.

  9. In CPT, what is the difference between a 'separate procedure' designation and an unlisted procedure code?

    A 'separate procedure' is bundled into a more comprehensive procedure when performed together and is only coded alone when it is the sole/independent service. An unlisted procedure code is used when no specific Category I code exists and requires a special report.

  10. What is a CPT modifier, and what do modifiers -26, -TC, -50, and -59 indicate?

    Modifiers add information without changing the code definition. -26 = professional component; -TC = technical component; -50 = bilateral procedure; -59 = distinct procedural service (separate from another procedure on the same day).

  11. What three key components determine the level of CPT E/M code selection (for codes still using them), and what 2021+ change applies to office visits?

    Historically: History, Examination, and Medical Decision Making (MDM). As of 2021, office/outpatient E/M (99202-99215) selection is based on either MDM level OR total time on the date of the encounter (history and exam no longer drive the level).

  12. What does HCPCS stand for, and what is the distinction between Level I and Level II HCPCS?

    Healthcare Common Procedure Coding System. Level I is CPT (AMA-maintained, physician services). Level II is alphanumeric codes (CMS-maintained) for products, supplies, and services not in CPT—such as DME, drugs, ambulance, and prosthetics.

  13. Describe the format of a HCPCS Level II code and give an example of what 'J' codes and 'E' codes represent.

    One letter (A-V) followed by four digits. J codes = drugs administered other than oral method (injectable/chemotherapy drugs). E codes = Durable Medical Equipment (DME).

  14. What is a HCPCS Level II modifier, and what do modifiers -LT/-RT and -GA represent?

    Alphanumeric two-character modifiers that refine a code. -LT/-RT = left side/right side of the body. -GA = waiver of liability statement (ABN) on file, signed by the patient, for a service expected to be denied.

  15. For outpatient/physician coding, what is the guideline regarding coding the 'reason for the visit' and confirmed diagnoses?

    Code the first-listed diagnosis as the main reason for the encounter/visit (the diagnosis chiefly responsible for the services provided). Code all documented confirmed coexisting conditions that affect treatment; do not code uncertain diagnoses in outpatient settings.

  16. What is the National Correct Coding Initiative (NCCI), and what two types of edits does it contain?

    NCCI (CMS) promotes correct coding and prevents improper payment from incorrect code combinations. It contains (1) Procedure-to-Procedure (PTP) edits—code pairs that shouldn't be reported together, and (2) Medically Unlikely Edits (MUEs)—maximum units of service per code per day.

  17. In outpatient surgery coding, what is the difference between the Z code for an encounter (first-listed) and additional codes for findings?

    For ambulatory/outpatient surgery, code the diagnosis for which the surgery was performed as the first-listed; if the postoperative diagnosis differs and is more definitive, the postoperative diagnosis should be selected as it is the most accurate.

  18. What is a Prospective Payment System (PPS), and how does it differ from fee-for-service/retrospective payment?

    A PPS pays a predetermined, fixed amount for a service based on a classification system, regardless of actual cost incurred. Retrospective fee-for-service pays after the fact based on charges/costs actually incurred.

  19. What classification system drives the inpatient PPS (IPPS), and what factors determine an MS-DRG?

    IPPS uses MS-DRGs (Medicare Severity Diagnosis Related Groups). Assignment is based on the principal diagnosis, surgical procedures (OR vs. non-OR), and the presence of CC (Complication/Comorbidity) or MCC (Major CC), plus discharge status and sometimes age/sex.

  20. How is the IPPS payment calculated using the DRG relative weight and hospital base rate?

    Payment = DRG relative weight x hospital base (blended) rate. The relative weight reflects the resource intensity of the DRG; the base rate is adjusted for wage index, teaching status (IME), and disproportionate share (DSH).

  21. What is the Case Mix Index (CMI), and what does a higher CMI indicate?

    CMI is the average of the DRG relative weights for all patients in a given period (sum of DRG weights / number of cases). A higher CMI indicates a more resource-intensive, sicker patient population and generally higher reimbursement.

  22. What classification systems are used by the Outpatient PPS (OPPS) and the Skilled Nursing Facility PPS?

    OPPS uses APCs (Ambulatory Payment Classifications), driven by CPT/HCPCS codes. SNF PPS uses PDPM (Patient-Driven Payment Model), which replaced RUGs and bases payment on patient characteristics from the MDS assessment.

  23. What payment systems are used for physician services, home health, and inpatient rehabilitation facilities?

    Physician = RBRVS (Resource-Based Relative Value Scale) with the Medicare Physician Fee Schedule. Home Health = HH PPS using PDGM (Patient-Driven Groupings Model). Inpatient Rehab = IRF PPS using CMGs (Case-Mix Groups) based on the IRF-PAI assessment.

  24. How is a physician fee calculated under RBRVS using RVUs?

    Payment = [(Work RVU x Work GPCI) + (Practice Expense RVU x PE GPCI) + (Malpractice RVU x MP GPCI)] x Conversion Factor. GPCIs are Geographic Practice Cost Indices adjusting for regional cost differences.

  25. Distinguish Medicare Part A, Part B, Part C, and Part D.

    Part A: hospital/inpatient, SNF, hospice, home health. Part B: physician services, outpatient, DME, preventive. Part C: Medicare Advantage (private plans combining A and B). Part D: prescription drug coverage.

  26. What is the difference between Medicare and Medicaid?

    Medicare is a federal program for people 65+, certain disabled persons, and those with ESRD/ALS—eligibility based on age/disability. Medicaid is a joint federal-state program for low-income individuals—eligibility based on financial need, with state-variable benefits.

  27. What is the purpose of an Advance Beneficiary Notice (ABN), and when is it required?

    An ABN is a written notice given to a Medicare beneficiary before providing a service that Medicare is likely to deny as not medically necessary, informing them they may be financially responsible. It must be issued before the service so the patient can make an informed decision.

  28. What are the major phases of the revenue cycle, from patient access through reimbursement?

    Front-end: scheduling/registration, insurance verification, prior authorization. Middle: charge capture, coding, documentation. Back-end: claim submission, payment posting, denial management, AR follow-up, and collections.

  29. What is a chargemaster (CDM), and what key data elements does it contain?

    The Charge Description Master is a comprehensive listing of all billable items/services. Key elements include: item description, CPT/HCPCS code, revenue code, charge/price, and department/general ledger code. It drives hard-coded outpatient charges.

  30. What is the difference between 'hard coding' and 'soft coding' in revenue cycle, and how does it relate to discharged not final billed (DNFB)?

    Hard coding = codes assigned automatically via the chargemaster (e.g., lab, radiology). Soft coding = codes assigned by HIM coders from documentation review (e.g., complex surgeries, inpatient). DNFB tracks accounts discharged but not yet billed, often due to incomplete coding—a key revenue cycle KPI to minimize.

  31. In coding compliance, what is the difference between 'upcoding' and 'unbundling'?

    Upcoding = assigning a higher-level/more expensive code than documentation supports to increase reimbursement. Unbundling = reporting component parts of a procedure separately instead of using a single comprehensive code, to increase payment. Both are fraudulent/abusive billing practices.

  32. What is a coding compliance plan, and what are the official documents that govern ethical coding practice?

    A formal program ensuring accurate, ethical coding consistent with regulations. Governance includes the AHIMA Standards of Ethical Coding, the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, and the OIG Compliance Program Guidance.

  33. What is a physician query, and what makes a query 'compliant' (non-leading)?

    A query is a communication tool to clarify ambiguous, incomplete, or conflicting documentation. A compliant query is non-leading—it presents clinical indicators and asks the provider to confirm/clarify without suggesting a specific diagnosis or indicating that a particular answer increases reimbursement.

  34. What is the difference between coding accuracy measured by 'code-level' vs. 'record-level (case) accuracy' in a coding audit?

    Record-level (case) accuracy counts a record as correct only if ALL codes (including sequencing/DRG) are correct—stricter. Code-level accuracy measures the percentage of individual codes assigned correctly across records. Record-level accuracy is typically lower and more meaningful for DRG impact.

Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies FAQ

What is in the Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies syllabus?

Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies is split into 4 chapters: ICD-10-CM Diagnosis Coding, ICD-10-PCS Procedure Coding, CPT and HCPCS Coding and Reimbursement Systems. Together they contain 13 topics and 34 sub-topics.

How many chapters are in Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies?

4 chapters, containing 13 topics and 34 sub-topics. The largest chapter is Reimbursement Systems, with 4 topics.

Are there flashcards for Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies?

Yes — a 54-card Medical Coding and Reimbursement Methodologies deck, printed in full in the flashcards section of this page and available in the Examius app with spaced repetition. The free plan covers one exam of your choice, including its flashcards; Examius Pro, a one-time purchase, unlocks every other exam and deck.