Health Information Management
Exam Materials
Course Introduction
Health Information Management is the systematic practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. This course covers the fundamentals of managing healthcare data, including data governance, information technology, privacy and security regulations, electronic health records, and quality improvement. Students will explore practices that ensure the accuracy, accessibility, and confidentiality of patient health information, while learning about compliance with legal and ethical standards in healthcare settings. The course prepares students for roles in health data management, supporting operational, clinical, and administrative decision-making processes.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2017 Edition 1st Edition by Karla R. Lovaasen
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Verified Questions 1611 Flashcards
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2
Chapter 1: The Rationale for and History of Coding
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) ICD-10-CM can be updated _________ times each year. Answer: two
Q2) To maintain their credentials,coders must earn __________.
Answer: continuing education units (CEUs) continuing education units CEUs
Q3) WHO stands for __________.
Answer: World Health Organization
Q4) Systematized Nomenclatures of Medicine
A)Has more than 100,000 members and was started in 1981
B)Translating diagnoses and procedures into special alphanumeric characters for the purposes of statistically capturing data
C)Grouping like items together for easy storage and retrieval
D)To maintain credentials,coders must earn these
E)Published by the College of American Pathologists,the most up-to-date system of nomenclature
F)The current coding classification system in use in the United States
Answer: E
Q5) Without the __________ system the comparison of data would be impossible. Answer: classification
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Chapter 2: The Health Record As
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42 Verified Questions
42 Flashcards
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Sample Questions
Q1) The reason,in the patient's own words,for presenting to the hospital is the
Answer: chief complaint
Q2) What is the definition of subjective complaint as it applies to a patient coming to a healthcare facility?
Answer: The problem stated in the patient's own words
Q3) What does AHQA stand for?
Answer: American Health Quality Association
Q4) In some cases a patient is ready to be discharged from the hospital,but at the last minute the patient develops a condition that requires him or her to stay an additional night.An example of when a patient might have to stay an additional night is when the patient ____.
A)is feeling better
B)has no pain
C)has no additional cough
D)develops a fever
Answer: D
Q5) Which report should be written or dictated immediately following a procedure.
Answer: Operative report
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Chapter 3: ICD-10-Cm Format and Conventions
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39 Flashcards
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Sample Questions
Q1) "__________" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship.
Answer: Due to or with
Q2) 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
Q3) Which statement is NOT true of inclusion terms?
A)An "inclusion note" under a code indicates that the terms excluded from the code are to be coded elsewhere.
B)The terms may be included under some codes.
C)These terms are the conditions for which that code number is to be used.
D)The inclusion terms are not necessarily exhaustive.
Answer: A
Q4) What does NEC stand for?
Answer: Not elsewhere classifiable
Q5) Why is it important for the coder to understand coding conventions?
Answer: Ensures accurate assignment and sequencing of codes
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Chapter 4: Basic Steps of Coding
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35 Verified Questions
35 Flashcards
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Sample Questions
Q1) What is the main term in "esophageal reflux"?
Q2) Synopsis of the events of a patient's hospital encounter
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
Q3) 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
Q4) What is the subterm in "rheumatoid arthritis"?
Q5) The __________,if available,is the first step in the process of record review for code selection.
Q6) What is the subterm in "infantile eczema"?
Page 6
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Chapter 5: General Coding Guidelines for Diagnosis
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27 Flashcards
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Sample Questions
Q1) In the inpatient setting,it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
A)True
B)False
Q2) Etiology/manifestation convention requires ____ code(s)to fully describe a single condition that affects multiple body systems.
A)one
B)two
C)three
D)zero
Q3) What is the diagnosis code(s)for posttraumatic osteoarthritis due to previous left femoral neck fracture (hip)?
Q4) A patient is admitted to the hospital with vomiting,diarrhea,and an inability to eat or drink.IV fluids are administered,and the patient is put on bowel rest.The following day the patient is discharged with a diagnosis of gastroenteritis and dehydration.What is the principal diagnosis?
Q5) What is the diagnosis code(s)for acute and chronic cholecystitis?
Q6) What is the diagnosis code(s)for acute and chronic renal failure?
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Chapter 6: Introduction to ICD-10-PCS
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127 Verified Questions
127 Flashcards
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Sample Questions
Q1) The cystic duct is in what body system?
Q2) Alphabetic Index entry for gastric banding (stomach)
Q3) Altering the route of passage of the contents of a tubular body part is bypass.
A)True
B)False
Q4) The body site for perirenal is peritoneum.
A)True
B)False
Q5) The entry,by puncture or minor incision,of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the operative site is an open approach.
A)True
B)False
Q6) Procedures that are performed using an open approach with percutaneous endoscopic assistance are coded to laparoscopic approach.
A)True
B)False
Q7) ____________________ examinations and procedures are performed with an instrument that examines any cavity of the body with the use of a rigid or a flexible scope.
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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
109 Flashcards
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Sample Questions
Q1) CT bilateral lungs using low osmolar contrast
Q2) Mechanical respiratory ventilation less than 24 hours
Q3) Any root operation in the medical and surgical section can be used in the osteopathic section.
A)True
B)False
Q4) Detoxification services are a procedure that can be coded in the substance abuse treatment section.
A)True
B)False
Q5) Fitting of voice prosthesis using voice analysis equipment
Q6) Diagnostic ultrasound right breast
Q7) Instruction of caregiver to assist patient with showering
Q8) 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
Q9) Physical therapy treatment to increase ROM shoulder Page 9
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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Sample Questions
Q1) Total right hip replacement with ceramic on polyethylene prosthesis,open approach,without bone cement
Q2) Laparoscopic-assisted vaginal hysterectomy
Q3) ESWL-right ureter
Q4) If a surgical procedure starts out as a laparoscopic approach,it may never be converted to an open procedure.
A)True
B)False
Q5) Root operation that involves cutting or separation only
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
Q6) Taking out or off a device from a body part is called ____.
Q7) Removal of mole right upper arm
Q8) Closed reduction of right radial fracture
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Q9) Bilateral fallopian tubal occlusion with Falope ring device,laparoscopic approach
Chapter 9: Symptoms, signs, and Abnormal Clinical and Laboratory
Findings Not Elsewhere Classified, and Z Codes
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Sample Questions
Q1) Gas pain: __________
Q2) The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla.The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago.The patient is no longer receiving any therapy for her cancer.A needle biopsy was done.The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.
Final Diagnosis: Lymphadenopathy left axilla;metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
A)R59.9,Z85.3,Z90.12,07B63ZX
B)R59.1,Z85.3,Z90.12,07B63ZZ
C)R59.0,Z85.3,Z90.11,07B53ZX
D)R59.0,Z85.3,Z90.12,07B63ZX
Q3) A ______________ is objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician.
Q4) ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
A)True
B)False
Q5) Screening for sickle cell disorder: __________
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Chapter 10: Certain Infectious and Parasitic Diseases
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62 Verified Questions
62 Flashcards
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Sample Questions
Q1) Trench mouth is coded to ____.
A)A69.0
B)A69.1
C)A27.9
D)A36.3
Q2) Patient was admitted with difficulty swallowing.EGD showed esophageal candidiasis.Patient is HIV positive.
A)B37.81,Z21,0DJ08ZZ
B)B37.89,B20,0DB17ZX
C)B20,B37.81,0DJ08ZZ
D)B20,B37.0,0DB38ZZ
Q3) Assign the code for infectious diarrhea.
Q4) What disease causes inflammation of the liver and can be caused by several different viruses?
Q5) What disease is caused by a fungus?
A)Syphilis
B)HIV
C)Gonorrhea
D)Candidiasis
Q6) Assign the code for Ebola virus.
Page 13
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Chapter 11: Neoplasms
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69 Flashcards
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Sample Questions
Q1) 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
Q2) A patient is admitted and taken to surgery for an open wedge resection of metastatic carcinoma to the liver.The patient was diagnosed with small-cell lung carcinoma 3 months ago.What codes are applicable?
A)C78.7,C34.90,0FB04ZX
B)C34.90,C78.7,0FB00ZZ
C)C78.7,C34.90,0FB00ZZ
D)C34.90,C78.7,0FB04ZX
Q3) Ovarian (left)malignancy with malignant ascites.Diagnostic paracentesis was performed and confirmed the malignant ascites.
A)R18.0,Z85.43,0W9G30Z
B)R18.0,C56.2,0W9G3ZX
C)C56.1,R18.8,0W9G3ZZ
D)C56.2,R18.0,0W9G3ZX
Q4) CDC stands for ____________________.
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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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71 Verified Questions
71 Flashcards
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Sample Questions
Q1) Familial erythrocytosis: __________
Q2) A 5-year-old boy was noted to have abnormal blood counts on preschool examination and was sent for admission to the hospital.A percutaneous bone marrow biopsy was performed.The mother stated that her son has been tired lately and does seem to bruise easily.Patient received red blood cell and platelet transfusions.
Final Diagnosis: Idiopathic aplastic anemia.
Procedure: Transfusions via peripheral vein.
Bone marrow biopsy,left iliac crest.
A)D61.3,079T3ZZ,30233N1,30233R1
B)D61.2,079P3ZX,30233N0,30233R0
C)D61.1,079T3ZZ,30233H0,30233J0
D)D61.3,07DR3ZX,30233N1,30233R1
Q3) ____ are medications that are used to prevent venous thrombi.
A)Antiplatelets
B)Anticonvulsant
C)Antidoted.
D)Anticoagulants.
Q5) Waldenstrom's hypergammaglobulinemia: __________ Page 15
Q4) Patient has anemia,thrombocytopenia,and neutropenia: __________
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Chapter 13: Endocrine, nutritional, and Metabolic Diseases
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Sample Questions
Q1) A patient is admitted with diabetic gangrene of the left little toe.The toe was completely amputated.The patient has uncontrolled type 1 diabetes.
A)E10.52,E10.65,0Y6Y0Z0
B)E11.65,E11.52,0Y6X0Z0
C)E11.52,E11.65,0Y6X0Z0
D)E10.65,E10.52,0Y6Y0Z0
Q2) Diet,monitoring blood sugars,and insulin or oral medications such as glyburide
A)Vitamin deficiencies
B)Malnutrition
C)Obesity
D)Diabetes
E)Hyperkalemia
F)Cystic fibrosis
G)Hypoparathyroidism
Q3) ____ is a condition that results in excessive circulating cortisol levels.
A)Hyperparathyroidism
B)Addison's disease
C)Cushing's syndrome
D)Diabetes insipidus
Q4) Diabetes mellitus with hypoglycemic coma: __________
Page 17
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Chapter 14: Mental, behavioral, and Neuro developmental Disorders
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72 Flashcards
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Sample Questions
Q1) Name one occurrence during birth that can cause intellectual disability.
Q2) The recurrent intense sexual urges and fantasies of the use of inanimate objects for sexual arousal or orgasm
A)Masochism
B)Fetishism
C)Exhibitionism
D)Sadism
E)Transvestism
F)Voyeurism
Q3) ____________________ is a structured program with the goal to stop and recover from the use of drugs or alcohol.
Q4) Dementia with wandering: __________
Q5) ____________________ is a progressive deterioration of mental faculties characterized by impairment of memory and one or more cognitive impairments.
Q6) Major depressive disorder,recurrent,moderate: __________
Q7) An impaired mental state in which the perception of reality has become distorted is called ____________________.
18
Q8) Panic agoraphobia: __________
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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) A college student is admitted with fever,headache,and a stiff neck.Lumbar puncture is performed in the ER,and lab results reveal pneumococcal meningitis.The patient is given IV fluids for volume depletion and IV antibiotics to treat meningitis.
A)G00.1,E86.9,009U3ZZ
B)R50.9,R51,M43.6,009U3ZX
C)R50.9,R51,M43.6,G00.1,009U3ZZ
D)G00.1,E86.9,009U3ZX
Q2) A disorder of the brain characterized by abnormal electrical discharges from the brain cells
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson's disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer's disease
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) Postprocedural status unspecified cardiac device
A)Z82.3
B)Z94.1
C)Z95.811
D)Z95.9
E)Z76.82
Q2) Patient comes to the hospital for repair of an abdominal aortic aneurysm.The repair is performed by implantation of synthetic graft in the abdominal aorta via percutaneous approach.
A)I71.3,04U04JZ
B)I71.4,04V03DZ
C)I71.3,04V04DZ
D)I71.4,04U03JZ
Q3) Family history of stroke
A)Z82.3
B)Z94.1
C)Z95.811
D)Z95.9
E)Z76.82
Q4) AF is the abbreviation for ____________________.
20
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Chapter 17: Diseases of the Respiratory System
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Sample Questions
Q1) A patient is admitted with SOB.The chest X-ray shows pneumonia with possible empyema formation in the left pleural cavity.A therapeutic thoracentesis of the left pleural cavity is performed to drain the empyema.Cultures are positive for Klebsiella. Discharge Diagnosis: Klebsiella pneumonia with empyema.What codes are applicable?
Q2) RAD stands for ____________________.
Q3) Idiopathic pulmonary fibrosis with transbronchial right lung biopsy via bronchoscope: __________
Q4) Escherichia coli pneumonia: __________
Q5) Patient was seen in the ER for sinus headache.Final diagnosis is acute ethmoidal sinusitis due to Streptococcus pneumoniae.
A)J01.20,B95.4
B)J02.21
C)J01.20,B95.3
D)J32.2
Q6) H1N1 influenza: __________
Q7) Eosinophilic asthma: __________
Q8) The condition where fluid accumulates in the lungs is called ____________________.
21
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) Which Z code is associated with family history of digestive disorders?
A)Z87.19
B)Z83.79
C)Z80.0
D)Z87.11
Q2) The squeezing or movement of food toward the stomach and down the digestive tract is called ____.
A)mastication
B)peristalsis
C)thrombosis
D)perforation
Q3) What is mastication?
Q4) Patient with vomiting and abdominal pain is admitted to the hospital.After workup,it is determined that the patient has appendicitis.The patient is taken to the OR for a laparoscopic appendectomy.The pathology report shows that the patient suffered from acute appendicitis with an abscess.
A)K35.3,R10.9,0DYJ0ZZ
B)K35.3,0DTJ4ZZ
C)R10.9,K35.1,0DTJ4ZZ
D)K35.9,R10.9,0DTJ0ZZ
Page 22
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Chapter 19: Diseases of the Skin and Subcutaneous Tissue
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Sample Questions
Q1) Diseases of the skin and subcutaneous tissues are coded ____.
A)G00-G99
B)M00-M99
C)L00-L99
D)C00-D49
Q2) Inflammation of the skin,also referred to as eczema,characterized by redness,itching,scaling,and crusting skin
A)Decubitus ulcer
B)Skin ulcers
C)Cellulitis
D)Stasis ulcer
E)Stasis dermatitis
F)Intertriginous dermatitis
G)Gangrene
H)Hives
I)Dermatitis
Q3) The skin is composed of ____________________ layers.
Q4) What are the three types of glands located in the skin?
Q5) Polymorphous light eruption from first-time use of a tanning booth: __________
Page 23
Q6) Another name for furuncle is a(n)____________________.
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) Subacute osteomyelitis of sacrum with decubitus sacral ulcer,stage 3.Staphylococcus aureus is the causative organism.
A)M46.28,L89.153,B95.61
B)M46.28,L89.153,B95.62
C)B95.61,M46.28,L89.153
D)M46.27,L89.152,B95.62
Q2) An 83-year-old woman with severe back pain is admitted.CT shows osteoporosis and possible compression fracture of the lumbar spine.The patient is seen by interventional radiology,and a percutaneous vertebroplasty is performed.
Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.
A)M81.0,M80.08xA,0QU03JZ
B)M80.08xG,0QS03ZZ
C)M80.08xA,0QU03JZ
D)M80.08xA,0QS03ZZ
Q3) Spinal decompression is a surgical procedure that frees the ____________________ in the spinal canal.
Q4) Ankylosis of right shoulder: __________
Q5) Kaschin-Beck disease,right ankle: __________
Page 24
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) When the site is known,urinary tract infections are assigned codes based on the site of the infection.
A)True
B)False
Q2) Acute and chronic pyelonephritis due to Pseudomonas: __________
Q3) 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
Q4) Acute kidney injury (nontraumatic): __________
Q5) Tight hymenal ring: __________
Q6) Priapism: __________
25
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Chapter 22: Pregnancy, childbirth, and the Puerperium
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Sample Questions
Q1) In ICD-10-CM,there are seventh characters to specify the fetus affected by the obstetric condition.
A)True
B)False
Q2) When a vaginal delivery occurs,the principal diagnosis should correspond to the main circumstance or complication of the delivery.
A)True
B)False
Q3) What is the Index term if the condition is affecting the pregnancy?
Q4) In ICD-10-CM the final character indicates the episode of care.
A)True
B)False
Q5) Complications of pregnancy,childbirth,and the puerperium are coded ____.
A)M00-M99
B)L00-L99
C)O00-O9A
D)Q00-Q99
Q6) What is an ectopic pregnancy?
Q7) Gestational edema,second trimester antepartum (25 weeks): __________
Q8) What does it mean when a pregnant woman is called primigravida?
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Chapter 23: Certain Conditions Originating in the Perinatal
Period and Congenital Malformations, deformations, and
Chromosomal Abnormalities
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Sample Questions
Q1) A disorder that involves incomplete development of the brain,spinal cord,and/or their protective coverings
A)Klinefelter's syndrome
B)Spina bifida
C)Meckel's diverticulum
D)Marfan syndrome
E)Tetralogy of Fallot
F)Down syndrome
Q2) What does LGA stand for?
Q3) Cesarean delivery at term with infant in fetal distress during labor: __________
Q4) If the baby scores a ____ or higher on the Apgar test 1 minute after birth,he or she is considered to be healthy.
Q5) Congenital conditions are always present,well defined,and diagnosed at birth. A)True
B)False Page 27
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Page 28
Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Sample Questions
Q1) A(n)____________________ fracture causes injury to the surrounding tissues.
Q2) Where are foreign bodies most likely to enter?
Q3) All of the following are symptoms of fat embolism syndrome EXCEPT ____.
A)tachycardia
B)elevated temperature
C)decreased temperature
D)hypoxemia
Q4) Open dislocation (open wound),right acromioclavicular joint,initial encounter:
Q5) Laceration on nose due to being hit on nose by surfboard while vacationing at the beach.Laceration of the skin was repaired.
A)S01.21xD,W21.89xA,Y92.832,Y93.18,0HQ1XZZ
B)S01.21xA,W21.89xA,Y92.832,Y93.18,Y99.8,0HQ1XZZ
C)S01.22xA,W21.89xA,Y92.832,Y99.8,0HQ1XZZ
D)S01.22xD,W21.89xA,0HQ1XZZ
Q6) Open-fracture fifth metatarsal on the right,initial encounter: __________
Q7) When a patient is unable to respond to people or to other stimuli,he or she is considered to have ____________________.
Q8) What are external cause codes? ____________________ Page 29
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Page 30
Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) Patient is being treated with hyperbaric oxygen therapy (HBOT)for decompression sickness when surfacing while scuba diving in the ocean.
A)T70.3xxA,W94.21xA,Y92.832,Y93.15,6A150ZZ
B)T70.3xxD,W94.21xD,Y92.832,Y93.15,6A150ZZ
C)T70.3xxS,W94.21xS,Y92.832,Y93.15
D)T70.9xxA,W94.21xA,Y92.832,Y93.15,6A150ZZ
Q2) Patient was admitted with cocaine-induced chest pain.Patient has a history of cocaine abuse.
A)T40.5x1A,R07.9,F14.10
B)R07.9,T40.5x1A,F14.10
C)T40.5x1A,R07.2,F14.20
D)T40.5x1S,R07.9,F14.10
Q3) Active treatment of nonhealing second-degree burn to right forearm due to hot iron while ironing (accidental): __________
Q4) Sunburned chest: __________
Q5) Debridement is one of the most common procedures performed on burn victims.
A)True
B)False
Q6) What are the four major types of abuse?
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Chapter 26: Complications of Surgical and Medical Care
Available Study Resources on Quizplus for this Chatper
48 Verified Questions
48 Flashcards
Source URL: https://quizplus.com/quiz/43725
Sample Questions
Q1) There is a time limit for complications to occur.
A)True
B)False
Q2) Patient admitted with an abscess due to Streptococcus of abdominal surgical wound,initial encounter.Cultures were positive for Streptococcus.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) Patient with a history of a kidney transplant comes to the ER with gastroenteritis.His history is positive for CKD,stage 2,and hypertension.
A)T86.10,I12.9,Z94.0
B)K52.9,I10,5N18.2,Z94.0
C)T86.10,I10,N18.2
D)K52.9,I12.9,N18.2,Z94.0
Q4) NSTEMI following laparoscopic appendectomy for acute appendicitis.Physician documents that the NSTEMI was due to the procedure: __________
Q5) Leaking silicone breast implant,initial visit: __________
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