Health Information Technology
Exam Answer Key
Course Introduction
Health Information Technology examines the use and management of technology within healthcare environments to improve patient care, streamline operations, and ensure the secure handling of health data. This course covers key topics such as electronic health records (EHRs), health information exchange, data privacy and security, and the regulatory frameworks impacting healthcare IT. Students will explore the integration of information systems in clinical settings, analyze the role of health informatics in decision-making, and evaluate contemporary tools and trends shaping the future of healthcare technology.
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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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) All of the following are members of the cooperating parties EXCEPT ____.
A)NCHS
B)AHA
C)AAPC
D)AHIMA
Answer: C
Q2) Compliance officers and programs are found only in healthcare organizations.
A)True
B)False
Answer: False
Q3) In a closed system such as the ICD-10-CM system, a disease or condition can be classified only in ____ location(s).
A)one
B)two
C)three
D)four
Answer: A
Q4) ICD-10-CM stands for __________.
Answer: International Classification of Diseases, 10th Revision, Clinical Modification
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Chapter 2:
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Sample Questions
Q1) A _________________ is usually written by the attending physician on a daily basis to describe how the patient is progressing and the plan of care.
Answer: progress note
Q2) UHDDS
A)Centers for Medicare and Medicaid Services
B)Temperature, pulse, and respiration
C)Uniform Hospital Discharge Data Set
D)Gastroesophageal reflux disease
Answer: C
Q3) What does MRI stand for?
Answer: Magnetic resonance imaging
Q4) When coding a record, where is one of the best places to begin?
Answer: The discharge summary if available.
Q5) What is the definition of subjective complaint as it applies to a patient coming to a health care facility?
Answer: The problem stated in the patient's own words
Q6) What does AHQA stand for?
Answer: American Health Quality Association
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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) Why is it important for the coder to understand coding conventions?
Answer: Ensures accurate assignment and sequencing of codes
Q2) The bolded subterm in the diagnostic statement poorly controlled diabetes is a(n) ____ modifier.
A)essential
B)nonessential
Answer: A
Q3) The bolded subterm in the diagnostic statement bacterial pneumonia is a(n) ____ modifier.
A)essential
B)nonessential
Answer: A
Q4) "____" is used in the Alphabetic Index to provide guidance when two conditions are related or have a causal relationship.
A)With
B)See condition
C)See category
D)And
Answer: A
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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) The main term is ____.
A)always identified in italics
B)a review of the patient's hospital course
C)a term identifying disease conditions or injuries
D)a word found in parentheses that enclose explanatory information that does NOT affect the code
Q2) In the discharge summary, a physician lists the __________ that were evaluated and treated and any procedures that were performed.
Q3) The __________, if available, is the first step in the process of record review for code selection.
Q4) What is the subterm in "aspiration pneumonia"?
Q5) What is the main term in "calculus of the ureter"?
Q6) What is the subterm in "rheumatoid arthritis"?
Q7) To be sure you have the correct diagnosis code, it is very important to go to the Alphabetic Index first and then to the Tabular List.
A)True
B)False
Q8) What is the main term in "infantile eczema"?
Q9) What is the subterm in "infantile eczema"?
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Chapter 5: General Coding Guidelines for Diagnosis
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) A patient is admitted to the hospital with Crohn's disease, hypertension, and rheumatoid arthritis for bowel resection. In the OR before incision, the patient develops tachycardia, and the procedure is canceled. What is the principal diagnosis?
Q2) What is/are the diagnosis code(s) for thoracolumbar scoliosis (neuromuscular) due to past history of poliomyelitis?
Q3) If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.
A)True
B)False
Q4) A patient who is a known diabetic is admitted for treatment of pneumonia. What is the principal diagnosis?
Q5) What is/are the diagnosis code(s) for acute and chronic respiratory failure?
Q6) If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.
A)True
B)False
Q7) What is/are the diagnosis code(s) for acute and chronic cholecystitis?
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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) Which of the following is a characteristic of ICD-10-PCS?
A)Codes are alphanumeric.
B)They are similar to ICD-10-CM diagnosis codes.
C)The number of codes is limited.
D)Codes are three to four digits.
Q2) It is required that a coder use the Index to assign an ICD-10-PCS code.
A)True
B)False
Q3) Uses an endoscopic instrument to examine and perform closed procedures within the thorax
A)Thoracoscopic approach
B)Arthroscopic approach
C)Laparoscopic approach
D)Endoscopic approach
Q4) A bone marrow transplant is coded in the administration section.
A)True
B)False
Q5) Total lobectomy of right upper lobe lung, open approach
Q6) Which character identifies the approach in an ICD-10-PCS code?
Q7) Alphabetic Index entry for fragmentation left ureteral stone
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Chapter 7: General Coding Guidelines for Other Medical-
and Surgical-Related Procedures and Ancillary Procedures
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109 Verified Questions
109 Flashcards
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Sample Questions
Q1) PPN infusion via peripheral vein
Q2) In the Administration section the fourth character, body system/region, identifies the site where the substance is administered.
A)True
B)False
Q3) Obstetric tables include procedures performed on the products of conception only.
A)True
B)False
Q4) IQ testing
Q5) Fitting of voice prosthesis using voice analysis equipment
Q6) Acupuncture can be coded in the other procedures section of ICD-10-PCS.
A)True
B)False
Q7) Detoxification services are a procedure that can be coded in the mental health section.
A)True
B)False
Q9) Phototherapy with Bili-lite, single treatment Page 9
Q8) Medication management for drug dependence with methadone maintenance
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Chapter 8: Coding Medical and Surgical Procedures
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66 Verified Questions
66 Flashcards
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Sample Questions
Q1) When more than one procedure is performed, the procedure that was performed first is the principal procedure.
A)True
B)False
Q2) Completely closing an orifice or lumen of a tubular body part is called ____.
Q3) Open CABG bypass of two coronary arteries using the saphenous vein (aorta to coronary artery) and one artery with the left internal mammary artery, which was used as a pedicle graft to coronary artery. The left greater saphenous vein was harvested via percutaneous endoscopic approach. Cardiopulmonary bypass machine was used during the procedure.
Q4) Each ____________________ should have its own written policy regarding the assignment of ICD-10-PCS codes.
Q5) Root operation that involves cutting or separation only
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
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Chapter 9: Symptoms, Signs,
and
Abnormal
Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
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60 Verified Questions
60 Flashcards
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Sample Questions
Q1) Problems with mother-in-law: __________
Q2) Subjective evidence of a disease or of a patient's condition as perceived by the patient
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) Objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician
A)A primary circumstance for using Z codes
B)Symptom
C)Screening exam
D)Is a main term in the Alphabetic Index
E)Sign
Q4) The NIHSS describes the level of consciousness in comatose patients.
A)True
B)False
Q5) Retained metal fragment: __________
Q6) Exposure to syphilis: __________
12
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Chapter 10: Certain Infectious and Parasitic Diseases
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64 Verified Questions
64 Flashcards
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Sample Questions
Q1) ____________________ is found as white plaques on the lips, inner cheeks, or tongue. It is seen in babies, people with cancer, and people with diabetes.
Q2) A patient was admitted with difficulty swallowing and is HIV positive. An EGD was performed and revealed candidal esophagitis. Patient was treated and discharged home in stable condition.
Q3) A patient was admitted to the hospital with jaundice and elevated liver function tests. Upon discharge, the physician documents jaundice due to acute hepatitis B.
A)B16.9
B)B16.9, R17
C)R17, R79.89, B16.9
D)B18.1
Q4) When a person carries an infectious disease and shows no ill effects, he or she is known as a(n) ____.
A)septicemic
B)asymptomatic carrier
C)symptomatic carrier
D)transmitter
Q5) Assign the code for Ebola virus.
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Chapter 11: Neoplasms
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70 Verified Questions
70 Flashcards
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Sample Questions
Q1) Preventive or ____________________ surgery is performed to remove tissue that has the potential to become cancerous.
Q2) Neutropenic fever with neutropenia due to chemotherapy for acute lymphocytic leukemia.
A)C91.00, T45.1x5A, C91.00
B)T45.1x5A, D70.1, R50.81, C91.00
C)D70.1, T45.1x5A, R50.81, C91.00
D)R50.81, T45.1x5A, D70.1, C91.00
Q3) Primary cancer of the cauda equina: __________
Q4) Smoking is associated with 100% of all oral cancers.
A)True
B)False
Q5) A patient is admitted with hematuria. The patient is a long-time cigarette smoker. A diagnostic cystoscope is performed with complete excision of a bladder dome lesion. The pathology report reveals transitional cell bladder carcinoma. A metastatic workup is performed with high suspicion for bone lesion. Smoking cessation advised for nicotine dependence. Discharge diagnosis: Bladder cancer with metastasis to the bone.
Q6) CDC stands for ____________________.
Q7) Metastasis to Zuckerkandl's organ: __________
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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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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) Neutropenic fever: __________
Q2) A patient takes Coumadin for chronic atrial fibrillation.
A)I48.1, Z79.01
B)I48.2, Z79.01
C)Z79.01
D)I48.0, Z79.02
Q3) A patient is admitted with sickle cell Hb-C crisis with acute chest syndrome. Patient is treated with pain medications. Patient has chronic pain due to avascular necrosis of the left shoulder (head of humerus). The avascular necrosis is due to the sickle cell disease. __________
Q4) Thrombocytopenia due to chronic alcoholism: __________
Q5) Anemia due to acute blood loss: __________
Q6) End-stage renal disease with erythropoietin-resistant anemia: __________
Q7) Childhood anemia: __________
Page 16
Q8) Sarcoidosis of the skin: ____________
Q9) Plasmacytosis: __________
Q11) Scorbutic anemia: __________
Q12) SCID stands for ____________________.
Q13) What is the function of leukocytes (WBCs)?
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Chapter 13: Endocrine, Nutritional, and Metabolic Diseases
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68 Verified Questions
68 Flashcards
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Sample Questions
Q1) What does NIDDM stand for?
Q2) Acquired absence of pancreas, partial
A)Z79.890
B)Z90.411
C)Z83.49
D)Z86.39
E)Z71.3
Q3) The ____ system works with the nervous system to maintain body activities and homeostasis and to respond to stress.
A)musculatory
B)circulatory
C)endocrine
D)skeletal
Q4) Familial hypercholesterolemia: __________
Q5) When blood sugar becomes abnormally low, it is called ____.
A)hyperglycemia
B)hypoglycemia
C)hyperpituitarism
D)hypopituitarism
Q6) Primary hyperparathyroidism: __________
18
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Chapter 14: Mental, Behavioral, and Neurodevelopmental Disorders
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) An adult female patient is admitted for treatment of anorexia nervosa. The patient has moderate malnutrition, severe electrolyte imbalance, and nutritional cardiomyopathy. The dietitian documents a BMI of 18.
A)F50.00, E44.0 E87.8, I43, Z68.1
B)E44.0, F50.00, E87.8, I43
C)E87.8, F50.02, E44.0, I43, Z68.1
D)F50.01, E44.1, E87.8, I43
Q2) What cognitive impairments can be caused by dementia?
Q3) Asexual transsexualism: __________
Q4) A 28-year-old man was brought to the ER by a friend who stated that the patient had been acting bizarrely. The patient has been irritable, pacing the apartment, and talking nonstop. He was admitted to the psychiatric unit for management of his manic symptoms.Final Diagnosis: Bipolar affective disease Severe manic phase. Recurrent episode with psychosis.
A)F31.2
B)F31.73
C)F31.74
D)F31.10
Q5) Major depressive disorder, recurrent, moderate: __________
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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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55 Verified Questions
55 Flashcards
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Sample Questions
Q1) How is hydrocephalus treated most commonly?
Q2) Which of the following is the most common diagnostic test for epilepsy?
A)EEG
B)MRI
C)Ultrasound
D)EMG
Q3) Pseudohole of the macula of the right eye: __________
Q4) What does the abbreviation "sz" stand for?
Q5) 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
Q6) Meningitis due to Klebsiella: __________
Q7) A(n) ____________________ is a device that is used to treat intractable epilepsy. Page 20
Q9) Arcus senilis of the left eye: __________
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) The two main types of heart failure are systolic and diastolic.
A)True
B)False
Q2) Patient comes into the ER after fainting at work. The physician determines that the fainting was caused by hypertensive urgency.
A)R55.0, R03.0
B)R55.0
C)I16.1, R55
D)I16.0
Q3) 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
Q4) Acute myocardial infarction, commonly referred to as a(n) ____________________, occurs when there is complete blockage of blood flow in a coronary artery.
Q5) What is the function of blood vessels?
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Chapter 17: Diseases of the Respiratory System
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73 Verified Questions
73 Flashcards
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Sample Questions
Q1) It is inappropriate for coders to assume a causal organism based on lab or radiology findings alone.
A)True
B)False
Q2) H1N1 influenza: __________
Q3) The condition where fluid accumulates in the lungs is called ____________________.
Q4) Which of the following is NOT categorized with high-risk potential for contracting pneumonia?
A)Someone who is in his or her first year of life
B)Someone who is in his or her early 20s
C)Someone who is elderly
D)Someone with AIDS
Q5) Idiopathic pulmonary fibrosis: __________
Q6) Chronic obstructive pulmonary disease is a term used to describe the accumulation of fluid in the pleural space.
A)True
B)False
Q7) Aspiration pneumonia with MRSA pneumonia: __________
Q8) Broncholithiasis: __________
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) 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
Q2) The patient has a diagnosis of upper esophageal stricture and a history of COPD. An EGD with dilatation of the stricture is performed.
A)K22.4, J44.9, 0D758DZ
B)K22.2, J44.9, 0D718ZZ
C)K22.5, J44.1, 0D717DZ
D)K22.2, J44.1, 0D718ZZ
Q3) What is an ulcer (such as of the stomach or intestine)?
Q4) Appendicitis with abscess: __________
Q5) Recurrent gangrenous inguinal hernia: __________
Q6) An ileostomy is very similar to a(n) ____________________ EXCEPT that the end of the small intestine is brought through the abdominal wall.
Q7) What happens to food once it arrives in the stomach?
Page 24
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Chapter 19: Diseases of the Skin and Subcutaneous System
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Sample Questions
Q1) A patient comes to the ER with a crusty, itchy rash. The diagnosis is impetigo of the legs with superimposed cellulitis. The patient is admitted to treat the cellulitis.
A)L03.115, L03.116, L01.00
B)L01.00, L031.19
C)L03.113, L01.00
D)L03.125, L01.00
Q2) The outer layer of skin is called the ____________________.
Q3) A skin condition also known as urticaria wherein the skin reacts with welts characterized by itching
A)Decubitus ulcer
B)Skin ulcers
C)Cellulitis
D)Stasis ulcer
E)Stasis dermatitis
F)Intertriginous dermatitis
G)Gangrene
H)Hives
I)Dermatitis
Q4) The sebaceous glands secrete an oily substance called
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) ____ is one of the most common diseases affecting the muscles; it is characterized by widespread muscle pain associated with chronic fatigue.
A)Postlaminectomy syndrome
B)Bursitis
C)Fibromyalgia
D)Rhabdomyolysis
Q2) Ball joints are small stabilizing joints located between and behind adjacent vertebrae.
A)True
B)False
Q3) ____________________ is a metabolic bone disorder that results in decreased bone mass and density.
Q4) Spinal stenosis is the widening or rupture of the spinal canal.
A)True
B)False
Q5) What does the abbreviation AKA stand for?
Q6) Ankylosis of right shoulder: __________
Q7) Calcification of lumbar disk: __________
Q8) Myelopathy is compression of the ____________________. Page 26
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) Postmenopausal atrophic vaginitis: __________
Q2) If causative bacteria are documented by the physician, this code should NEVER be coded in addition to the urinary tract infection.
A)True
B)False
Q3) Patient was admitted to the hospital with acute renal failure due to dehydration. Patient will have to be rehydrated slowly due to CHF.
A)E86.0, N18.9, I50.9
B)N17.9, E86.1
C)N17.9, E86.0, I50.9
D)E86.0, N17.9, I50.9
Q4) Ulceration of the vulva: __________
Q5) ____________________ is the presence of blood in the urine.
Q6) ____________________ is a chronic condition in which endometrial material, the tissue that lines the inside of the uterus, grows outside the uterus and attaches to other organs in the pelvic cavity.
Q7) Chronic interstitial cystitis: __________
Q8) Leukoplakia of vulva: __________
Q9) Hypotonic bladder: __________
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Chapter 22: Pregnancy, Childbirth, and the Puerperium
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Sample Questions
Q1) In ICD-10-CM, the final character indicates the episode of care.
A)True
B)False
Q2) The patient is admitted in labor at 38 weeks'gestation. She labors for 24 hours, when it is noted that the baby is in fetal distress. The patient is taken to the OR for an emergency C-section (LTCS). She delivers a healthy baby.
A)O77.9, Z3A.38, Z37.0, 10D00Z1
B)O77.8, Z3A.38, Z38.003
C)O77.8, Z3A.38, Z37.0, 10D00Z1
D)O77.9, Z3A.38, Z38.00, 10D00Z0
Q3) Before delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q4) A pregnancy in which the egg is implanted outside the cavity of the uterus is an __________ pregnancy.
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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) Cleft lip occurs in approximately 1 in every 2000 babies.
A)True
B)False
Q2) Vaginal delivery of infant with a birth weight of 4600 g at 42 weeks'gestation; physician documents postterm infant who is large for dates: __________
Q3) Occurs only in males, characterized as a sex chromosome disorder that occurs when an extra X chromosome is present
A)Klinefelter syndrome
B)Spina bifida
C)Meckel diverticulum
D)Marfan syndrome
E)Tetralogy of Fallot
F)Down syndrome
Q4) For coding purposes, what is the perinatal period considered?
Q5) A 53-year-old male with polycystic kidney disease is admitted. Lab tests reveal worsening kidney function, and the patient is classified at stage V chronic kidney disease. Workup for possible transplant is completed during admission, and the patient is placed on a transplant list. What codes are applicable? __________
Page 30
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Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Sample Questions
Q1) Organ or tissue replaced by transplant-bone
A)Z94.6
B)Z89.211
C)Z89.432
D)Z87.820
E)Z91.81
Q2) Which of the following is NOT a common site for a laceration?
A)Above the eyebrows
B)Scalp
C)Stomach
D)Knees
E)Face
Q3) 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. __________
Q4) When air or gas bubbles get into the bloodstream, it is called a(n)
Q5) A(n) ____________________ is a break in a bone that occurs because of underlying disorders that weaken the bone, including malignancy, benign bone tumors, metabolic disorders, infection, and osteoporosis.
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) Which of the following can be used to treat burns?
A)Antibiotics
B)Antiinflammatories
C)Corticosteroids
D)All of the above
Q2) A 2-year-old child was admitted with an accidental electrical burn to the upper lip. The child was at home (single family) and had bitten on an electrical cord. The mother immediately sought medical attention. The burn was a full-thickness burn. Local wound care was performed. The patient was not having any breathing problems. Further intervention will depend on how the burn heals.Final Diagnosis: Full-thickness burn to upper lip due to electrical current
A)T20.42xA, W86.1xxA, Y92.010
B)T20.32xA, W86.0xxA, Y92.019
C)T20.32xD, W85.xxxD, Y92.020
D)T20.32xS, W86.0xxS, Y92.016
Q3) Sunburned chest: __________
Q4) Z codes are never assigned in relation to injuries, burns, adverse effects, and poisoning.
A)True
B)False
Page 32
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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/42599
Sample Questions
Q1) Occurs when the fracture fragments have united but are not properly aligned.
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q2) Patient had an outpatient ERCP for extraction of a common bile duct stone. The patient developed acute abdominal pain and was admitted to rule out post ERCP pancreatitis.Impression: Post-ERCP pancreatitis
A)K91.89, K80.50, K85.90, Y83.8, 0FC98ZZ
B)K86.1, K80.51, K91.89, Y83.9, 0FC98ZZ
C)K85.10, K80.60, Y84.9, 0F998ZZ
D)K85.90, K80.61, Y84.8, 0F798ZZ
Q3) The term dehiscence means ____.
A)breathing in a foreign object
B)opening a surgical wound
C)caused by medical treatment
D)small amount of urine
Q4) Mechanical complication of gastrostomy: __________
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