Fundamentals of Health Information Technology
Exam Questions
Course Introduction
Fundamentals of Health Information Technology introduces students to the essential concepts, systems, and applications used in managing healthcare information. The course covers the structure and function of health information systems, electronic health records, data standards, and the legal, ethical, and regulatory aspects related to health data. Students will also explore the key components of health information exchange, data security, and the impact of technology on patient care, provider workflows, and the healthcare industry as a whole. This foundational course provides the knowledge required to understand, assess, and work with health information technologies in various healthcare settings.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2018 Edition 1st Edition by Karla R. Lovaasen
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26 Chapters
1616 Verified Questions
1616 Flashcards
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Chapter 1: The Rationale for and History of Coding
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Sample Questions
Q1) Work for ICD-10-CM began in ____.
A)1963
B)1973
C)1983
D)1993
Answer: C
Q2) Without the __________ system, the comparison of data would be impossible. Answer: classification
Q3) Personal health information can be shared with ____.
A)those who have a need to know
B)people requesting information on the phone
C)your neighbors
D)all of the above
Answer: A
Q4) The ICD-10-CM classification system is a closed system composed of ____.
A)diseases
B)symptoms
C)injuries
D)all of the above
Answer: D
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Chapter 2:
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Sample Questions
Q1) TPR
A)Centers for Medicare and Medicaid Services
B)Temperature, pulse, and respiration
C)Uniform Hospital Discharge Data Set
D)Gastroesophageal reflux disease
Answer: B
Q2) The AHIMA practice brief says that a physician query should____.
A)"lead" the physician
B)contain precise language
C)be written on scratch paper
D)sound presumptive
Answer: B
Q3) Every facility should have the same policies and procedures with regard to the query process.
A)True
B)False
Answer: False
Q4) What year did the Uniform Hospital Discharge Data Set (UHDDS) mandate that hospitals must report a common core of data?
Answer: 1974
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Chapter 3: ICD-10-Cm Format and Conventions
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39 Verified Questions
39 Flashcards
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Sample Questions
Q1) What does an Excludes2 note in ICD-10-CM mean to a coder?
Answer: That a condition he or she may be looking for is not contained in that code and that another code may be required
Q2) "Diseases of the skin and subcutaneous tissue (L00-L99)" represents a ____.
A)chapter
B)section
C)category
D)subcategory
Answer: A
Q3) An "Excludes1 note" under a code indicates that the terms excluded from the code are to be coded elsewhere.
A)True
B)False
Answer: True
Q4) "__________" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship.
Answer: Due to or with
Q5) What are the two tables found in the Alphabetic Index in ICD-10-CM?
Answer: Neoplasm Table and the Table of Drugs and Chemicals
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Chapter 4: Basic Steps of Coding
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Sample Questions
Q1) The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.
A)True
B)False
Q2) What is the subterm in "rheumatoid arthritis"?
Q3) After a code has been selected from the Alphabetic Index, it must be verified in this A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers
Q4) What is the main term in "infantile eczema"?
Q5) What is the main term in "rheumatoid arthritis"?
Q6) What is the subterm in "infantile eczema"?
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Chapter 5: General Coding Guidelines for Diagnosis
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Sample Questions
Q1) Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
A)True
B)False
Q2) A patient comes to the hospital with unstable angina. Serial cardiac enzymes and EKGs are performed, and anterolateral myocardial infarction is confirmed. The patient develops congestive heart failure on day 2 of the hospital stay. What is the principal diagnosis?
Q3) What is/are the diagnosis code(s) for acute and chronic cholecystitis?
Q4) Codes for symptoms, signs, and ill-defined conditions are NOT to be used as a principal diagnosis when a related definitive diagnosis has been established.
A)True
B)False
Q5) The selection of codes A00.0 through T88.9, Z00-Z99.8 is NOT used frequently to describe the reason for the admission/encounter.
A)True
B)False
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Chapter 6: Introduction to Icd-10-PCS
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Sample Questions
Q1) Which character identifies the body part in an ICD-10-PCS code?
Q2) Taking or letting out fluids and/or gases from a body part is called ____.
A)extirpation
B)fragmentation
C)extraction
D)drainage
Q3) The cystic duct is in what body system?
Q4) The vas deferens is in what body system?
Q5) Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane are called ____.
A)percutaneous
B)open
C)via natural or artificial opening
D)external
Q6) Which of the following is a characteristic of ICD-10-PCS?
A)Codes have a decimal point.
B)It is similar to ICD-10-CM codes.
C)There are a limited number of codes.
D)Codes are seven characters.
Page 8
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Chapter 7: General Coding Guidelines for Other Medicaland
Surgical-Related Procedures and Ancillary Procedures
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109 Verified Questions
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Sample Questions
Q1) MRI procedures are located in the nuclear medicine section.
A)True
B)False
Q2) In the extracorporeal assistance and performance section, the definition for assistance is completely taking over a physiological function by extracorporeal means.
A)True
B)False
Q3) When a code from Section X is assigned, an adjunctive code from another table also needs to be assigned.
A)True
B)False
Q4) Radionuclide is the second character in the nuclear medicine section.
A)True
B)False
Q5) CPAP, 48 hours
Q6) Fascial release of the cervical region-osteopathic treatment
Q7) Suture removal can be coded in the other procedures section of ICD-10-PCS.
A)True
B)False
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Chapter 8: Coding Medical and Surgical Procedures
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Sample Questions
Q1) Placement of central venous catheter with the tipat the cavoatrial junction
Q2) PTCA of left anterior descending and left circumflex
Q3) Freeing a body part from an abnormal physical constraint is called ____.
Q4) Laparoscopic orchiopexy-right undescended testicle
Q5) Root operation that puts in/puts back or moves some/all of a body part
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
Q6) Removal of drainage device from right pleural cavity, external approach
Q7) Modifying the natural anatomic structure of a body part without affecting the function of the body part is called ____.
Q8) Therapeutic paracentesis of peritoneal cavity, percutaneous
Q9) "Low cervical cesarean section" would be identified by the fifth character approach.
A)True
B)False
Page 10
Q10) Open annuloplasty of the mitral valve with Carpentier-Edwards ring
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Chapter 9: Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings Not Elsewhere Classified, and Z Codes
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Sample Questions
Q1) The infant was seen in the ER for fever. Physician documented fever due to vaccination.
A)R50.81
B)R50.82
C)R50.83
D)R50.2
Q2) Done in the absence of any signs or symptoms
A)A primary circumstance for using Z codes
B)Symptom
C)Screening exam
D)Is a main term in the Alphabetic Index
E)Sign
Q3) Another name for the coma scale is ______________ Coma Scale score.
Q4) Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________
Q5) ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
A)True
B)False
Q6) What is meant by screening exam or test? Page 11
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Chapter 10: Certain Infectious and Parasitic Diseases
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Sample Questions
Q1) Assign the code for Colorado tick fever.
Q2) Category B20 is assigned for ____________________.
Q3) The systemic inflammatory response to infection or trauma; includes fevers, tachycardia, and leukocytosis
A)SIRS
B)Bacteremia
C)Septicemia
D)Gonorrhea
E)Septic shock
F)Sepsis
Q4) Assign the code for Ebola virus.
Q5) What virus is spread to individuals by a mosquito bite?
Q6) ____ is an infection caused by a mycobacterium; it can attack any body part, but it usually attacks the lungs.
A)Anthrax
B)Tuberculosis
C)Meningococcus
D)Clostridium difficile
Q7) Assign the code for chickenpox.
Q8) TB stands for ____________________.
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Chapter 11: Neoplasms
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Sample Questions
Q1) Malignant growth originating from epithelial tissue
A)Well differentiated
B)Sarcomas
C)Fibromas
D)Metastasis
E)Leukemias
F)Melanomas
G)Carcinomas
H)Undifferentiated
I)Myeloma
J)Grading
K)Primary site
L)Staging
M)Adenocarcinoma
Q2) When admission is for the management of dehydration due to malignancy or therapy and only dehydration is being treated, the dehydration is coded first, followed by the code(s) from the malignancy.
A)True
B)False
Q3) Gastrointestinal stromal tumor of the duodenum, malignant
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Chapter 12: Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving the Immune
Mechanism
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Sample Questions
Q1) Pancytopenia due to AIDS.
A)B20
B)D61.818, B20
C)B20, D61.818
D)D61.818, Z21
Q2) Scorbutic anemia: __________
Q3) The normal red blood cell count for females is ____.
A)12 to 14 g/dL
B)150,000 to 350,000/mm3
C)4.0 million to 5.5 million/mm3
D)8.0 million to 9.5 million/mm3
Q4) A patient is being admitted for a total splenectomy (open approach) for treatment of idiopathic thrombocytopenic purpura.
A)D69.0, 07BP0ZZ
B)D69.3, 07TP4ZZ
C)D69.2, 07TP4ZZ
D)D69.3, 07TP0ZZ
Q5) Neutropenic fever: __________
Page 15
Q6) Waldenstrom hypergammaglobulinemia: __________
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Page 16
Chapter 13: Endocrine, Nutritional, and Metabolic Diseases
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Sample Questions
Q1) ____ is a condition that results in excessive circulating cortisol levels.
A)Hyperparathyroidism
B)Addison disease
C)Cushing syndrome
D)Diabetes insipidus
Q2) Gigantism occurs when there is hypersecretion of hGH before puberty and when there is a proportional overgrowth of all body tissues, especially the long bones.
A)True
B)False
Q3) A patient was admitted to the hospital with DKA. Labs showed glycosuria, ketonuria, and acidosis. Patient was admitted and was started on a sliding scale of insulin for type 1 DM. Patient's past history includes retinopathy. Patient's at-home medications include insulin.Discharge Diagnosis: Diabetic ketoacidosis
A)E10.11, E10.319
B)E10.319, E10.10
C)E10.10, E11.319
D)E10.10, E10.319
Q4) Primary hyperparathyroidism: __________
Q5) What does NIDDM stand for?
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Chapter 14: Mental, Behavioral, and Neurodevelopmental Disorders
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Sample Questions
Q1) Major depressive disorder, recurrent, moderate: __________
Q2) Mental disorders are very particular about the body system they affect. A)True B)False
Q3) In ICD-10-CM, mild alcohol use disorder codes to alcohol abuse. A)True
B)False
Q4) Patient was seen in the ER for dizziness, fatigue, and difficulty concentrating. Patient was seen for a head injury a couple of weeks ago. Physician documents postconcussional syndrome.
A)F07.81
B)F07.89
C)R42, R53.83, R41.3
D)F07.81, R42, R53.83
Q5) What are the two most common mood disorders?
Q6) A patient has a history of PTSD and arrives at the ER with extreme anxiety. The patient has been noncompliant with medications and recently has been under a great deal of stress and indicates suicidal ideation. The patient is admitted for monitoring and reinstitution of medications for exacerbation of chronic PTSD.
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Chapter 15: Diseases of the Nervous System, Diseases of
the Eye and Adnexa, and Diseases of the Ear and Mastoid Process
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Sample Questions
Q1) Mastoid cholesteatoma of the right ear: __________
Q2) Disorder of the optic nerve resulting in vision loss
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer disease
Q3) Patient came to the ER after falling off her horse at the county fair rodeo. X-rays reveal two fractured ribs on the left. Patient is admitted for acute pain control.
A)S22.42xA, G89.11, V80.010A, Y92.39, Y93.52
B)G89.18, S22.42xA, V80.010A, Y92.39, Y93.52
C)G89.11, S22.42xA, V80.010A, Y92.39, Y93.52
D)S22.42xA, R52, V80.010A, Y92.39, Y93.52
Page 19
Q4) Decreased ocular pressure with papilledema: __________
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) Blood thinners (Coumadin, Plavix, Ticlid); rate control: calcium channel blockers: Cardizem, verapamil; beta blockers: atenolol, Lopressor, Inderal, digoxin, Lanoxin
A)Angina
B)Atrial fibrillation
C)Congestive heart failure
D)Hypertension
Q2) What is the function of blood vessels?
Q3) Inflammation of the covering of the heart
A)Transient ischemic attack
B)Atherosclerosis
C)Aneurysm
D)Pericarditis
E)Endocarditis
F)Cardiomyopathy
G)Conduction disorder
H)Diagnostic cardiac catheterization
Q4) What is the function of the heart?
Q5) Stenosis of bilateral carotid arteries: __________
Q6) Prinzmetal angina: __________
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Chapter 17: Diseases of the Respiratory System
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Sample Questions
Q1) Idiopathic pulmonary fibrosis: __________
Q2) A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis due to previous cerebral infarction. Sputum cultures reveal Pseudomonas.Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria
A)J69.0, J15.1, I69.391, I69.352
B)J15.0, J69.0, I69.391, I69.359
C)J69.0, J15.1, I69.391, R13.10, I69.359
D)J18.9, J15.1, I69.391, R13.10, I69.359
Q3) In ICD-10-CM, if a respiratory condition occurs in more than one site and is not specifically indexed, each site should be coded separately.
A)True
B)False
Q4) Child was seen in the ER complaining of sore throat. Patient was diagnosed and treated for recurrent acute streptococcal tonsillitis.
A)J02.9
B)J02.0
C)J03.00
D)J03.01
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) What is the abbreviation for esophagogastroduodenoscopy?
Q2) Ostomies are surgically created openings into the body. Enterostomies and colostomies are created to discharge waste products from the body.
A)Both statements are true
B)Both statements are false
C)The first statement is true; the second is false
D)The first statement is false; the second is true
Q3) Which Z code is associated with family history of digestive disorders?
A)Z87.19
B)Z83.79
C)Z80.0
D)Z87.11
Q4) What drug could be given to treat a gastric ulcer?
A)Ciprofloxacin
B)Metronidazole
C)Pepcid
D)Compazine
Q5) Appendicitis with abscess: __________
Q6) Assign the code for hematemesis: __________
Q7) Name one purpose of the small intestine.
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Chapter 19: Diseases of the Skin and Subcutaneous System
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Sample Questions
Q1) The sebaceous glands secrete an oily substance called ____________________.
Q2) In ICD-10-CM, decubitus ulcers use a combination code for location and stage.
A)True B)False
Q3) A patient is admitted from the nursing home with suspected aspiration pneumonia. The attending physician documents that the patient has pressure ulcers on both buttocks. The left side has a stage 2 ulcer, and the right side has a stage 1 ulcer.
A)J69.0, L89.322, L89.311
B)J18.9, L89.301, L89.319
C)J18.9, L98.419
D)J69.0, L98.411, L98.412
Q4) The skin and its accessory organs are part of the ____________________ system.
Q5) The assignment of the code for unstageable pressure ulcer should be based on clinical documentation.
A)True B)False
Q6) Skin grafts can be only full-thickness skin grafts.
A)True B)False
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) Arthroscopic surgery is a highly invasive surgery that involves the use of instruments to perform surgery through very large incisions.
A)True
B)False
Q2) Calcification of lumbar disk: __________
Q3) Spinal decompression is a surgical procedure that frees the ____________________ in the spinal canal.
Q4) Which of the following make(s) up the musculoskeletal system?
A)Bones
B)Ligaments
C)Tendons
D)Cartilage
E)All of the above
Q5) Necrotizing fasciitis, also called ____________________, is a rare but serious condition in which an infection occurs in the tissues below the skin. It usually is caused by group A Streptococcus.
Q6) What does the abbreviation SLE stand for?
Q8) Right plantar fasciitis: __________ Page 24
Q7) Degenerative polyarticular arthritis: __________
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Page 25
Chapter 21: Diseases of the Genitourinary System
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Q1) An abnormal passage between two internal organs or leading from an organ to the surface of the body
A)Urolithiasis
B)Nephrotic syndrome
C)Fistula
D)Prostatitis
E)Urinary tract infections (UTIs)
F)Hemodialysis
G)Endometritis
H)Renal colic
I)Mastitis
J)Acute renal failure
Q2) Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.
Q3) Acute kidney injury (nontraumatic): __________
Q4) Hypotonic bladder: __________
Q5) CKD stage 2 in patient who has a kidney transplant: __________
Q6) Vesicoureteral reflux with nephropathy of the right kidney: __________
Q7) Vesicoperineal fistula: __________
Page 26
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Chapter 22: Pregnancy, Childbirth, and the Puerperium
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Q1) Missed abortion: __________
Q2) What is tested for in a female's urine sample to confirm that she is pregnant?
Q3) What happens in a molar pregnancy?
Q4) The process of milk production is ______________________.
Q5) In ICD-10-CM, there is a seventh character to specify the fetus affected by the obstetric condition.
A)True
B)False
Q6) What is an ectopic pregnancy?
Q7) The patient is 9 weeks' pregnant. She is admitted for an elective abortion. The physician performs a vacuum D&C to terminate the pregnancy.
A)Z33.2, 10A07Z6
B)O02.1, 10D17ZZ
C)O03.9, 10A07ZZ
D)O20.0, 10A07Z6
Q8) Mother with mastitis due to nursing. Delivered 8 days ago: __________
Q9) In ICD-10-CM, the final character indicates the episode of care.
A)True
B)False
Q10) A term that means before delivery is _____________________. Page 27
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Chapter 23: Certain Conditions Originating in the Perinatal
Period and Congenital Malformations, Deformations, and
Chromosomal Abnormalities
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Q1) What does AGA stand for?
Q2) What is a congenital anomaly?
Q3) Child is seen in pediatrician's office. She has a diagnosis of Down syndrome with ADHD, sleep apnea, and mild mental retardation. Her medications are reviewed, and a suggestion is made to have a sleep study.
A)Q90.0, F70, G47.30, F90.8
B)Q90.0, F79, G47.39, F90.9
C)Q90.9, F70, G47.30, F90.0
D)Q90.9, F79, G47.39, F90.9
Q4) There is abnormal fetal heart rate or rhythm during labor, and infant is therefore delivered by C-section. Mother was instructed on discharge to put the baby in front of the window in the sun to alleviate the mild jaundice. In addition, a lactation consult was performed during this stay because the baby was having difficulty breastfeeding.
A)Z38.01, P92.5, P59.9
B)Z38.00, P92.8, P59.3
C)Z38.00, P03.811, P92.8, P59.9
D)Z38.01, P03.810, P92.5, P59.3
Q6) For coding purposes, what is the perinatal period considered? Page 29
Q5) Cesarean delivery at term of interlocking twins, twin A: __________
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Page 30
Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Q1) Where is the best place to look for the petechial rash that forms from fat embolism syndrome?
Q2) In ICD-10-CM, if a fracture is not specified, it is coded to nondisplaced.
A)True
B)False
Q3) Lower limb amputation status-foot
A)Z94.6
B)Z89.211
C)Z89.432
D)Z87.820
E)Z91.81
Q4) Anaphylactic shock due to ingestion of milk: __________
Q5) Fat embolism syndrome usually is present within _____ to _____ hours after the injury.
Q6) A 7-year-old child is admitted to the hospital with fractured shaft of the right humerus after falling out of a tree. The patient is taken to the OR for ORIF. __________
Q7) Name some diagnostic tools used to diagnose injuries.
Q8) Sprained left ankle, initial encounter: __________
Q9) A(n) ____________________ fracture causes injury to the surrounding tissues. Page 31
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Q1) Full-thickness skin loss
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q2) External cause code(s) are never used to identify the cause and intent of the injury or poisoning.
A)True
B)False
Q3) All of the following are true of the "rule of nines" EXCEPT ____.
A)the genitalia are 1%
B)the head and neck are 9%
C)each arm is 9%
D)the anterior trunk is 9%
E)each leg is 18%
Q4) Debridement is one of the most common procedures performed on burn victims. A)True
B)False
Q5) First- and second-degree burn of face due to gas flame from stove in kitchen at patient's house while cooking: __________
33
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Chapter 26: Complications of Surgical and Medical Care
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Sample Questions
Q1) Pneumonitis due to organism growing in ventilation (air conditioning) system:
Q2) Patient was admitted with an abscess caused by Streptococcus of abdominal surgical wound, initial encounter. Cultures were positive for Streptococcus spp. The abscess of the skin was incised and drained.
A)T81.4, A49.1, Y84.9, 0H97X0Z
B)T81.4, L02.211, B95.5, Y84.9, 0H97Z0Z
C)T81.4xxA, L02.211, B95.5, Y83.9, 0H97XZZ
D)T81.4xxA, A49.1, Y83.9, 0H97XZZ
Q3) If the documentation is unclear whether the diagnosis was the result of a procedure or condition, a physician query should be initiated.
A)True
B)False
Q4) Leaking silicone breast implant, initial visit: __________
Q5) Codes under subcategory T86 are used ____.
A)only for complications of transplanted organs
B)only for rejection of transplanted organs
C)for both complications and rejection of transplanted organs
D)for none of the above reasons
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