Healthcare Data Management
Textbook Exam Questions
Course Introduction
Healthcare Data Management explores the principles and practices involved in the collection, storage, retrieval, and analysis of data within healthcare systems. The course covers topics such as data governance, patient privacy regulations (like HIPAA), data quality assurance, interoperability standards, and the application of health informatics tools for improving clinical and administrative decision-making. Students will gain hands-on experience with databases and electronic health records (EHRs), understand how data supports evidence-based medicine, and discuss the challenges of implementing robust data management strategies in a dynamic healthcare environment.
Recommended Textbook
Step by Step Medical Coding 2016 1st Edition by Carol
J. Buck
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Chapter 1: Reimbursement, Hipaa, and Compliance
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Sample Questions
Q1) Who is the largest third-party payer in the nation?
A)Blue Cross Blue Shield
B)Aetna
C)Cigna
D)the government
Answer: D
Q2) Medicare Part A pays for:
A)professional services and durable medical equipment
B)hospital/facility care
C)physician services and durable medical equipment
D)hospital/facility care and durable medical equipment
Answer: B
Q3) Kickbacks from patients are allowed under certain circumstances according to Medicare guidelines.
A)True
B)False
Answer: False
Q4) OBRA ________________________________________
Answer: Omnibus Budget Reconciliation Act
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Chapter 2: An Overview of ICD-10-CM
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Sample Questions
Q1) The I-10 has instructional notations to provide guidance.
A)True
B)False
Answer: True
Q2) The following are characteristics of the ICD-10-CM index:
A)Main terms are in bold type.
B)Subterms are indented under the main term.
C)Only the first four characters of some codes are given.
D)All of the above.
Answer: D
Q3) There are 21 chapters in the ICD-10-CM.
A)True
B)False Answer: True
Q4) Notable improvements in the content and format of the ICD-10-CM include expansion of signs and symptoms codes.
A)True
B)False Answer: False
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Chapter 3: ICD-10-CM Outpatient Coding and Reporting
Guidelines
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Sample Questions
Q1) Patient admitted to observation following a highway accident in which he was the driver of the car that was struck by another car. No injuries indicated during this initial encounter.
ICD-10-CM Codes: ___________________, ______________________
Answer: Z04.1, V43.52XA
Q2) Assign Z01.89, Encounter for other specified special examinations, for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses.
A)True
B)False
Answer: True
Q3) Encounter for blood type testing prior to surgery.
ICD-10-CM Code: ___________________
Answer: Z01.83
Q4) In the inpatient hospital setting, probable, suspected, and rule-out diagnoses cannot be reported by the facility as though the condition exists.
A)True
B)False
Answer: False
5
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Chapter 4: Using ICD-10-CM
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Sample Questions
Q1) Hypertensive heart disease NOS.
ICD-10-CM Code:____________________
Q2) Subsequent encounter for malunion of displaced fracture of shaft of the first metacarpal bone, right hand.
ICD-10-CM Code:____________________
Q3) Arteriosclerosis of native arteries of the left leg with gangrene.
ICD-10-CM Code:____________________
Q4) The Official Guidelines for Coding and Reporting are updated every year by CMS and AMA.
A)True
B)False
Q5) It is important to follow any cross-reference instructions in the Index of the I-10, such as see also.
A)True B)False
Q6) Acute and chronic systolic (congestive) heart failure.
ICD-10-CM Code:____________________
Q7) Acute and chronic prostatitis due to Escherichia coli bacterial infection.
ICD-10-CM Codes: _________________, _________________,
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Chapter 5: Introduction to CPT
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Sample Questions
Q1) What year was CPT first developed and published?
A)1966
B)1970
C)1983
D)none of the above
Q2) CPT stands for:
A)Current Physician's Terminology
B)Current Procedure Terminology
C)Current Procedural Terminology
D)Current Procedural Terms
Q3) If a coder is unable to locate a code that describes the exact service provided, it is acceptable to use a code that approximates the service provided.
A)True
B)False
Q4) Surgical care only
A)-76
B)-51
C)-54
D)-50
Q5) Appendix C of the CPT manual contains examples of ____________________ codes.
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Chapter 6: Introduction to Level II National Codes HCPSC
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Sample Questions
Q1) How often are Category III codes released?
A)annually
B)twice a year
C)every 3 years
D)as often as necessary
Q2) What is the HCPCS Level II code for Injection, gadoterate meglumine, 0.1 ml?
Q3) J codes do not include drug _____________.
Q4) K codes are used to identify:
A)The drugs administered and the amount or dosage given
B)Vision/Hearing services
C)The use of durable medical equipment
D)Diagnostic Radiology Services
Q5) What year did CMS develop and publish HCPCS?
A)1966
B)1970
C)1983
D)none of the above
Q6) Chemotherapy drugs J9000-J9999 include the ____________________ of the drug.
8
Q7) Codes beginning with letters ___, ___, ___, and ___ are for temporary assignment until a definitive decision can be made about appropriate code assignment.
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Chapter 7: Modifiers
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Sample Questions
Q1) Modifier -52, reduced services, is used to indicate:
A)a service was discontinued
B)changes to the description of the code
C)a service was reduced without changing the definition of the code
D)the procedure was terminated at the request of the patient
Q2) Modifiers may affect:
A)health care premiums
B)type of treatment provided
C)the way payment is made by a third-party payer
D)code selection
Q3) What modifier would you use if you were coding only for the professional component of a diagnostic procedure? ____________________
Q4) Mr. Jones is admitted to the hospital by the orthopedic surgeon for severe hip pain. The ortho surgeon provides an initial hospital visit during which it is determined that Mr. Jones has a fractured hip that will require surgical intervention. Mr. Jones is taken later that day to the OR where Dr. Ortho performs the surgical procedure to repair Mr. Jones' hip. Which modifier would you use for the hospital visit? ____________________
Q5) ____________________ lists some HCPCS modifiers in the CPT book.
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Chapter 8: Evaluation and Management EM Services
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Sample Questions
Q1) CLINIC NOTE
CC: Patient presents for routine examination
SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination.
OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.
ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.
Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________
Q2) Complete the following blanks that refer to the three factors that the coder must consider in the assignment. ____________________ of service, ____________________ of service, ____________________ status
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Chapter 9: Anesthesia
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Sample Questions
Q1) What is the type of sedation that allows a procedure to be performed without pain to the patient, but the patient is not completely asleep?
A)block
B)conscious or moderate
C)general
D)regional
Q2) Anesthesia for burr holes.
CPT Code: ____________________
Q3) The modifier "-AA" is an example of what type of modifier?
A)CPT
B)HCPCS
C)ICD-10-CM
D)None of the above
Q4) Anesthesia for diagnostic arthroscopic procedure of the knee joint.
CPT Code: ____________________
Q5) Assign a CPT anesthesia code for repair of cleft palate.
CPT Code: ____________________
Q6) Anesthesia for tracheobronchial reconstruction.
CPT Code: ____________________
Q7) ____________________ of the CPT manual lists some HCPCS modifiers.
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Chapter 10: Surgery Guidelines and General Surgery
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Sample Questions
Q1) Information given in the notes preceding a subsection is also contained in the section Guidelines.
A)True
B)False
Q2) What code is used to report routine postoperative care?
A)No code
B)99212
C)99024
D)99211
Q3) The correct code for an unlisted procedure for the breast is:
A)11949
B)99499
C)19499
D)14949
Q4) Excision including simple closure of benign lesions of the skin includes this type of anesthesia:
A)local
B)general
C)spinal
D)none of the above
Page 12
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Chapter 11: Extension 1: Chapter-Specific Guidelines:
ICD-10-CM Chapters 1-10
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Sample Questions
Q1) Encounter for screening for HIV due to high-risk heterosexual behavior.
ICD-10-CM Codes: _____________________, _____________________
Q2) Acute bilateral lacrimal canaliculitis due to Staphylococcus aureus.
ICD-10-CM Codes: ____________________, ____________________
Q3) Acute lower respiratory infection (Streptococcus, group A) in a patient with COPD.
ICD-10-CM Codes: ____________________, ____________________,
Q4) When the reason for the encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the first-listed diagnosis.
A)True
B)False
Q5) Sickle-cell crisis with acute chest syndrome.
ICD-10-CM Code: _____________________
Q6) Ulcer with necrosis of the muscle of the left ankle, due to atherosclerosis of native vessel of the left leg.
ICD-10-CM Codes: ____________________, _____________________
Page 13
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Chapter 13: Musculoskeletal System
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Sample Questions
Q1) Arthrocentesis is aspiration of a joint, and the codes used to report the service are in the range of ____________________.
Q2) A patient presents to the orthopedic office complaining of pain in the wrist. Upon examination, the physician determines that the patient has a ganglion cyst. The physician injects the ganglion cyst with Xylocaine to reduce the pain with guidance. What is the correct code?
A)20600
B)20605
C)20611
D)20612
Q3) Name four of the five graft types represented in the musculoskeletal subsection.
Q4) The application of a cranial halo is a form of:
A)insertional device
B)implantation fixation
C)external fixation
D)internal fixation
Q5) Scar revision of amputation site lower right arm (ulna and radius).
CPT Code: ____________________
Q6) Surgical arthroscopy of the shoulder, rotator cuff repair. CPT Code: ____________________
Page 14
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Chapter 14: Integumentary System
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Q1) repair
A) to remedy, replace, or heal
B) suffix for molding or surgically forming
C) free flow or withdrawal of fluids from a wound or cavity
D) cutting or taking away
E) to unite parts by stitching them together
F) inspection of body organs or cavities by the use of a lighted scope that may be placed through an existing opening or through a small incision
G) scraping of a cavity using a spoon-shaped instrument
H) forcing a fluid into a vessel or cavity
I) suffix for suturing
J) suffix for puncture of a cavity
K) suffix for removal of part or all of an organ of the body
L) removal of a small piece of living tissue for diagnostic examination
M) surgically cutting into
N) binding or tying off, as in constricting blood flow of a vessel or binding fallopian tubes for sterilization
O) suffix for incision into
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Chapter 14: Respiratory System
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Sample Questions
Q1) Which of the following terms does not describe the nasal turbinates?
A)exterior
B)superior
C)inferior
D)middle
Q2) A "direct" laryngoscopic procedure means that the physician uses a tongue depressor to hold the tongue down and view the epiglottis with a mirror.
A)True
B)False
Q3) Flexible bronchoscopy with use of laser therapy to relieve stenosis.
CPT Code: ____________________
Q4) In what Surgery subsection would you find the code for the incision and drainage of a nasal abscess using an external approach to the abscess?
A)Integumentary System
B)Respiratory System
C)Evaluation and Management
D)Medicine
Q5) Diagnostic, indirect laryngoscopy with vocal cord injection of Gelfoam.
CPT Code: ____________________
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Chapter 15: Extension 2: Chapter-Specific Guidelines:
ICD-10-CM Chapters 11-14
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Sample Questions
Q1) Patient with alcohol dependence is found to have chronic gastric atrophy.
ICD-10-CM Codes:____________________, ____________________
Q2) Keratoderma in a patient with Reiter's disease of the right shoulder.
ICD-10-CM Codes:_____________________, _____________________
Q3) Ruptured popliteal cyst.
ICD-10-CM Code:____________________
Q4) Patient with arthropathy of left hip associated with dysentery due to enteritis Yersina enterocolitica.
ICD-10-CM Codes: _____________________, _____________________
Q5) A stage 2 pressure ulcer is considered a full-thickness loss of skin. A)True B)False
Q6) Chronic ulcerative proctitis with fistula.
ICD-10-CM Code:____________________
Q7) Ruptured appendix with generalized peritonitis.
ICD-10-CM Code:_____________________
Q8) Cyst of the salivary gland.
ICD-10-CM Code:_____________________
Q9) Acquired hallux valgus, right foot. Page 17
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Chapter 16: Cardiovascular System
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Sample Questions
Q1) Direct repair of aneurysm associated with occlusion of the vertebral artery.
CPT Code: ____________________
Q2) Cardiovascular stress test codes are used for:
A)exercise-induced studies
B)pharmacologically-induced studies
C)both a and b
D)neither a nor b
Q3) Mr. O'Brien presents to his cardiologist's office complaining of chest pain. Dr. McCoy, the cardiologist, decides to obtain a cardiovascular stress test. Because Dr. McCoy's office does not have the proper equipment to perform this test, he sends Mr. O'Brien to the hospital for the test. Dr. McCoy accompanies Mr. O'Brien and supervises the stress test as well as provides his interpretation and written report. Report Dr. McCoy's service.
CPT Codes: ____________________, ____________________
Q4) Duplex scan of aorta, complete study.
CPT Code: ____________________
Q5) Pulmonary endarterectomy with embolectomy requiring cardiopulmonary bypass.
CPT Code: ____________________
Q6) Venous bypass graft for occlusive disease, femoral-popliteal.
CPT Code: ____________________
Page 19
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Chapter 17: Hemic, Lymphatic, Mediastinum, and Diaphragm
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Sample Questions
Q1) Suprahyoid lymphadenectomy.
CPT Code: ____________________
Q2) Lymphadenitis
A) Overlapping
B) Grafting tissue from one source to another
C) Inflammation of lymph nodes
D) Cutting into the mediastinum
Q3) The stem cell harvesting in 38205 is the collection of stem cells from the bone marrow.
A)True
B)False
Q4) This bone marrow is taken from a close relative, so there is a genetic similarity.
A)allogeneic
B)transgenic
C)autologenic
D)biogenic
Q5) The physician performs an extensive drainage of a lymph node abscess. CPT Code: ____________________
Q6) The mediastinum category code range is ____________________.
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Chapter 18: Digestive System
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Sample Questions
Q1) Examination of the rectum and sigmoid colon
A) Colonoscopy
B) Proctosigmoidoscopy
C) Sigmoidoscopy
D) Laparoscopy
Q2) A diagnostic, transoral, flexible esophagoscopy was performed. During the procedure an esophageal polyp was found and removed by hot biopsy forceps. CPT Code: ____________________
Q3) A physician is placing a nasogastric tube using fluoroscopic guidance. CPT Code: ____________________
Q4) The first step in choosing the correct digestive endoscopic procedure code is to identify the ____ of the procedure.
A)extent
B)complexity
C)urgency
D)position
Q5) Plastic repair of the cleft lip/nasal deformity primary bilateral, one of two stages. CPT Code: ____________________
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Chapter 19: Urinary and Male Genital Systems
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Q1) The patient requires the lysis of post-circumcision penile adhesions.
CPT Code: ____________________
Q2) Ureteral endoscopy through an established ureterostomy with irrigation and the removal of a foreign body.
CPT Code: ____________________
Q3) A complete transurethral electrosurgical resection of the prostate.
CPT Code: ___________________
Q4) A nephrectomy is the excision of the renal pelvis.
A)True
B)False
Q5) Removal of urine from the bladder
A) Prostatectomy
B) Retroperitoneal
C) Nephrectomy
D) Manometric study
E) Bladder aspiration
F) Calculus
Q6) Urethral biopsy.
CPT Code: ____________________
22
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Chapter 20: Reproductive, Intersex Surgery, Female Genital
System, and Maternity Care and Delivery
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Sample Questions
Q1) A fetal non-stress test is completed on a 36-week pregnancy. The correct code would be:
A)59050
B)59012
C)59020
D)59025
Q2) External cephalic version without tocolysis.
CPT Code: ____________________
Q3) Code a diagnostic hysteroscopy.
CPT Code: ____________________
Q4) You would expect to code a service for an amniocentesis using a code from the Female Genital System subsection and a code from the ____ section.
A)Medicine
B)Anesthesia
C)Radiology
D)E/M
Q5) Amniocentesis. Code only the procedure, not the radiological service.
CPT Code: ____________________
CPT Code: ____________________ Page 23
Q6) Surgical hysteroscopy with lysis of multiple intrauterine adhesions.
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Chapter 21: Extension 3: Chapter-Specific Guidelines :
ICD-10-CM Chapters 15-21
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Q1) Accidental asphyxiation due to smothering under pillow, initial encounter.
ICD-10-CM Code: ____________________
Q2) Anoxia due to high altitude, initial encounter.
ICD-10-CM Code: _____________________
Q3) A congenital anomaly is an abnormality one was born with.
A)True
B)False
Q4) Malignant hydatidiform moles are reported as a neoplasm of uncertain behavior of the placenta.
A)True B)False
Q5) Salpingitis following complete spontaneous abortion.
ICD-10-CM Code: ____________________
Q6) Fever, unknown origin.
ICD-10-CM Code: ____________________
Q7) The outcome of delivery is indicated on the mother's medical record only.
A)True B)False
Page 25
Q8) Pulmonary embolism following incomplete spontaneous abortion.
ICD-10-CM Code: ____________________
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Chapter 22: Endocrine and Nervous Systems
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Q1) Destruction of infraorbital nerve with neurolytic agent. CPT Code: ____________________
Q2) The physician resects an easily accessible arteriovenous malformation (AVM) in the infratentorial region of the brain. CPT Code: ____________________
Q3) Diagnostic lumbar spinal puncture. CPT Code: ____________________
Q4) The initials that indicate a shunting procedure are:
A)CPC
B)SCP
C)CSF
D)SFP
Q5) Neuroplasty is the:
A)injection of an anesthetic agent into a nerve
B)decompression of intact nerves
C)destruction of a nerve
D)all of the above
Q6) Complex repair of intracranial arteriovenous malformation, supratentorial. CPT Code: ____________________
Q7) Name the four glands represented in the Endocrine subsection.
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Chapter 23: Eye, Ocular Adnexa, Auditory, and Operating Microscope
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Q1) Otoplasty of the right ear, with size reduction. CPT Code: ____________________
Q2) The transparent part of the eye is the ____________________.
Q3) Removal of a superficial foreign body in the external left eye. CPT Code: ____________________
Q4) The codes in the Eye and Ocular Adnexa subsection are bilateral codes.
A)True B)False
Q5) Cataract and lens replacement uses ____ different approaches.
A)3 B)2
C)4 D)1
Q6) Bilateral repair of blepharoptosis with frontalis muscle technique. CPT Code: ____________________
Q7) The destruction codes in the Posterior Segment subsection include one or more sessions.
A)True B)False
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Chapter 24: Radiology Section
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Q1) X-ray photograph of the spinal cord following administration of radiopaque substance into the subarachnoid space
A)venography
B)lymphangiography
C)magnetic resonance
D)myelogram
E)cholangiography
F)computed tomography
G)angiography
H)pelvimetry
I)ultrasound
J)tomography
Q2) Selective spinal angiography, supervision and interpretation.
CPT Code: ____________________
Q3) Transvaginal ultrasound of a pregnant uterus using real-time image documentation.
CPT Code: ____________________
Q4) A cardiac magnetic resonance imaging for morphology and function without contrast.
CPT Code: ____________________
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Chapter 25: Pathology/Laboratory Section
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Q1) A dipstick urinalysis for ketones.
CPT Code: ____________________
Q2) colon, total resection
A) Level II
B) Level III
C) Level IV
D) Level V
E) Level VI
Q3) Code a hepatitis A, IgM antibody; hepatitis B core antibody, IgM; hepatitis C antibody, all ordered at the same time.
CPT Codes: ____________________, ____________________,
Q4) A stool test for Helicobacter pylori.
CPT Code: ____________________
Q5) A drug screening for methamphetamine, single class method.
CPT Code: ____________________
Q6) A definitive drug screening for amphetamine.
CPT Code: ____________________
Q7) Sodium, urine.
CPT Code: ____________________
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Chapter 26: The Medicine Section
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Q1) Hearing test using pure tone audiometry; air only.
CPT Code: ____________________
Q2) Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens for aphakia, both eyes.
CPT Code: ____________________
Q3) OTH
A)subcutaneous
B)intrathecal
C)inhalant
D)other routes
E)various routes
F)intramuscular
G)intravenous
Q4) Home visit for stoma care and maintenance of a patient's colostomy.
CPT Code: ____________________
Q5) A 3-hour and 15-minute infusion of a chemotherapeutic agent.
CPT Codes: ____________________, ____________________
Q6) The code range for Special Otorhinolaryngologic Services in the Medicine section is
31
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Chapter 27: Inpatient Coding
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Q1) In the inpatient setting, a CPT code would be assigned for a procedure code.
A)True
B)False
Q2) The root operation that is defined as taking or letting out of fluids and/or gases in a part of a body is:
A)division
B)dilation
C)creation
D)drainage
Q3) The American Hospital Association is responsible for the development of ICD-10-PCS.
A)True
B)False
Q4) Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma. What is the principal diagnosis?
A)the reason for the patient's outpatient procedure
B)a code for cancellation of the procedure
C)an aftercare V code
D)exacerbation of asthma
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