Healthcare Documentation and Coding Exam Questions
Course Introduction
This course introduces students to the principles and practices of healthcare documentation and coding, emphasizing the critical role accurate records play in patient care, reimbursement, and regulatory compliance. Students will explore the healthcare documentation process, including medical terminology, formats, and standards used in creating comprehensive clinical records. The course provides an overview of the major coding systems, such as ICD, CPT, and HCPCS, teaching students to translate medical diagnoses, procedures, and services into standardized codes. Ethical and legal considerations, confidentiality, and data security in medical documentation are also covered, preparing students for success in healthcare administrative and coding roles.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2017 Edition 1st Edition by
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26 Chapters
1611 Verified Questions
1611 Flashcards
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Karla R. Lovaasen
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) HIPAA stands for __________ of 1996.
Answer: Health Insurance Portability and Accountability Act
Q2) Continuing education units (CEUs)
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: D
Q3) In ICD-10-CM the CM stands for ____.
A)Clinical Modification
B)Centers for Medicaid and Medicare
C)Core Measures
D)Chief Medical Officer
Answer: A
Q4) WHO stands for __________.
Answer: World Health Organization
Page 3
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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) A query should contain all of the following items EXCEPT ____.
A)date of service
B)amount of increased reimbursement due to query
C)patient name
D)area for provider signature
Answer: B
Q2) 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
Q3) What is the goal of the physician query process?
Answer: To improve physician documentation and coding professionals' understanding of the unique clinical situation
Q4) Sometimes ____ will be used to help diagnose a patient's condition.
A)X-rays
B)history and physical
C)documentation
D)a discharge disposition
Answer: A
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4
Chapter 3: ICD-10-Cm Format and Conventions
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39 Verified Questions
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) The bolded subterm in the diagnostic statement cortical cataract is a(n)____ modifier.
A)essential
B)nonessential Answer: B
Q3) 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
Q4) 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
Q5) The term "with" in the code title requires documentation of what?
Answer: That both conditions linked by the term "with" must be present and documented for this code to be assigned
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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) A cross-reference instruction in the code book
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
Q2) A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.
A)True
B)False
Q3) The main terms usually are nouns and/or disease conditions.
A)True
B)False
Q4) What is the subterm in "esophageal reflux"?
Q5) 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
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Sample Questions
Q1) What are the diagnosis code(s)for acute and chronic pancreatitis?
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) The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.
A)True
B)False
Q4) 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?
Q5) A patient who is a known diabetic is admitted for treatment of an ulcer of the left great toe.What is the principal diagnosis?
Q6) What is the diagnosis code(s)for acute and chronic renal failure?
Q7) What is 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 character identifies the approach in an ICD-10-PCS code?
Q2) The body site for perirenal is peritoneum.
A)True
B)False
Q3) Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part is called ____.
A)reattachment
B)release
C)transfer
D)division
Q4) Cutting off all or a portion of the upper or lower extremities is ____.
A)destruction
B)fragmentation
C)detachment
D)resection
Q5) The body site for perirenal is kidney.
A)True
B)False
Q6) Thoracentesis,right pleural cavity,therapeutic
Q7) The trachea is in what body system?
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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) What is the section value for radiation oncology?
Q2) Instruction of caregiver to assist patient with showering
Q3) Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
A)True
B)False
Q4) The seventh character identifies whether the procedure is a physical rehabilitation procedure or a diagnostic audiology procedure.
A)True
B)False
Q5) The first character value for a physical rehabilitation or diagnostic audiology procedure is B.
A)True
B)False
Q6) The approach for chiropractic manipulation is always internal.
A)True
B)False
Q7) Placement of nasal packing,right nare
Q8) Proton radiation (beam)therapy for brain metastasis Page 9
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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66 Verified Questions
66 Flashcards
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Sample Questions
Q1) Bilateral fallopian tubal occlusion with Falope ring device,laparoscopic approach
Q2) Total right hip replacement with ceramic on polyethylene prosthesis,open approach,without bone cement
Q3) Any procedure that affects payment or reimbursement must be reported.
A)True
B)False
Q4) Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part is called ____.
Q5) Heart transplant,cadaver donor with extracorporeal circulation auxiliary during the open heart surgery
Q6) Laparoscopic-assisted vaginal hysterectomy
Q7) Laparoscopic cholecystectomy converted to open cholecystectomy
Q8) Change of nephrostomy tube
Q9) Open thyroidectomy with removal of the entire right lobe
Q10) ESWL-right ureter
Q11) Frenulotomy for treatment of ankyloglossia
Page 11
Q12) Moving all or a portion of a body part to its normal location or other suitable location is called ____.
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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 patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting.The patient had a low-grade fever.A diagnosis of acute appendicitis is made,and the patient is taken to the OR for removal of the appendix via open approach.
A)K35.80,R10.31,R11.2,R50.9,0DTJ4ZZ
B)R10.31,R11.2,R50.9,K35.80,0DTJ0ZZ
C)K35.80,0DTJ4ZZ
D)K35.80,0DTJ0ZZ
Q2) Which of the following is NOT true of status codes?
A)A status code is informative because the status may affect the course of treatment and its outcome.
B)A status code is distinct from a history code.
C)A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
D)All of the above are correct.
Q3) Encounter for admission examination for prisoner: __________
Q4) Patient is admitted for workup of normal pressure hydrocephalus because of ataxic gait.NPH is ruled out,and patient is discharged home: __________
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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) Tuberculosis usually occurs in populations with weaker immune systems.This would include all of the following EXCEPT ____.
A)people with HIV
B)substance abusers
C)teenagers
D)young children
Q2) Another name for a cold sore is herpes simplex type ____.
A)I
B)II
C)III
D)none of the above is correct
Q3) Z21 is a code used for patients with HIV who have no symptoms and who have never had an AIDS-defining or AIDS-related illness.
A)True
B)False
Q4) Assign the code for bubonic plague.
Q5) ____________________ is found as white plaques on the lips,inner cheeks,or tongue.It is seen in babies,people with cancer,and diabetics.
Q6) Assign the code for Ebola virus.
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Chapter 11: Neoplasms
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69 Flashcards
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Sample Questions
Q1) Categorizing a particular cancer that assists in determination of a patient's treatment plan
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) A(n)____________________ is an abnormal tissue that grows by cellular proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth cease.
Q3) The administration of cancer-killing drugs is called ____________________.
Q4) Glossopalatine fold carcinoma: __________
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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) ____ are medications that are used to prevent venous thrombi.
A)Antiplatelets
B)Anticonvulsant
C)Antidoted.
D)Anticoagulants.
Q2) Coagulopathy due to chronic liver disease: __________
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) ____________________ anemia results from abnormal or excessive destruction of red blood cells.
Q5) Postoperative anemia: __________
Q6) Childhood anemia: __________
Q7) Allergic vasculitis: __________
Q8) Familial erythrocytosis: __________ Page 16
Q9) What is the function of leukocytes (WBCs)?
Q10) ____________________ is an increased number of white cells in the blood.
Q11) Bandemia: __________
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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) The correct abbreviation for diabetes mellitus is ____________________.
Q2) A patient is admitted because of cystic fibrosis with pulmonary exacerbation.Sputum cultures grew Pseudomonas,and antibiotics are adjusted accordingly.The patient is also treated for hypernatremia and dehydration.
a.E84.8,B96.5,E86.0,E87.0
b.E84.0,B96.5,E86.0,E87.0
c.E84.0,B96.4,E87.0
d.B96.5,E84.0,E86.0,E87.0
Q3) In ICD-10-CM there is no designation for out-of-control diabetes mellitus.
A)True
B)False
Q4) When there is hypersecretion of hGH after puberty,a condition called acromegaly,where does the overgrowth occur?
Q5) 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
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Chapter 14: Mental, behavioral, and Neuro developmental Disorders
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) What do ADD and ADHD stand for?
Q2) Patient is admitted with abdominal pain.After investigation,it is determined that the patient has alcoholic gastritis.Patient has a history of alcohol dependence and has no desire to stop drinking.
A)F10.220,K29.21
B)K29.21,F10.220
C)F10.20,K29.20
D)K29.20,F10.20
Q3) Patient presented to the ER requesting detox.Patient had a previous admission for heroin dependence 2 years ago.Patient used about $50 per day and occasionally smoked cocaine.Patient is unemployed.Patient was admitted,and the detoxification protocol was implemented.The patient did experience some mild withdrawal symptoms.The patient was discharged after 3 days and was instructed to attend 90 NA meetings in 90 days and to find a sponsor.
Discharge Diagnosis: Heroin dependence with withdrawal. Cocaine abuse.
A)F11.21,F14.120,HZ5DZZZ
B)F11.20,F14.14,Z56.0,HZ91ZZZ
C)F11.229,F14.10,HZ2ZZZ
D)F11.23,F14.10,Z56.0,HZ2ZZZZ
Page 19
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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
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Sample Questions
Q1) How is hydrocephalus treated most commonly?
Q2) Bilateral vitreous floaters: __________
Q3) Patient is admitted for a senile cataract in the right eye to be removed by phacoemulsification with IOL replacement via percutaneous approach.
A)H25.21,08RK3JZ
B)H25.89,08DK3ZZ
C)H25.9,08RJ3JZ
D)H25.11,08DJ3ZZ
Q4) A patient is admitted for pain control.The patient has metastatic prostate cancer to the vertebrae and liver.The patient is started on a PCA pump,and pain is more manageable.
A)C61,G89.3,C78.7,C79.51
B)M54.9,G89.3,C61,C79.51
C)G89.3,Z85.46,C78.7,C79.51
D)G89.3,C61,C78.7,C79.51
Q5) All of the following are symptoms of meningitis EXCEPT ____.
A)vomiting
B)sensitivity to darkness
C)headache
D)high fever Page 20
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) The ____ is the middle layer of the heart composed of cardiac muscle.
A)epicardium
B)myocardium
C)endocardium
D)none of the above is correct
Q2) Acute myocardial infarction,commonly referred to as a(n)____________________,occurs when there is complete blockage of blood flow in a coronary artery.
Q3) AF is the abbreviation for ____________________.
Q4) 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
Q5) Prinzmetal angina: __________
Q6) What is the function of blood vessels?
Q7) Stenosis of bilateral carotid arteries: __________
Page 22
Q8) ____________________ is the sudden loss of heart function.
Q9) MI is the abbreviation for ____________________.
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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 laboratory or radiology findings alone.
A)True
B)False
Q2) Aspiration pneumonia with MRSA pneumonia: __________
Q3) Patient is admitted with status asthmaticus.Patient was started on albuterol treatments.Patient has been intubated on previous admissions.Patient is positive for sickle cell trait and is on methadone for treatment of heroin dependence.What codes are applicable?
Q4) What is the definition of infection?
Q5) Family history of asthma
A)Z82.5
B)Z83.6
C)Z87.891
D)Z85.22
E)Z48.24
F)Z77.090
G)Z93.0
Q6) What is the major organ of the respiratory system?
Q7) Broncholithiasis: __________
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Chapter 18: Diseases of the Digestive System
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60 Verified Questions
60 Flashcards
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Sample Questions
Q1) What are the three parts of the small intestine?
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) Patient comes to the ER with severe abdominal pain and a long history of alcoholism.Physician documents that patient is currently drinking a fifth of liquor a day.Patient is admitted to the hospital with a diagnosis of acute pancreatitis secondary to alcohol use.
A)K85.80,F10.10
B)K85.20,F10.20
C)K85.90,F10.10
D)K85.00,F10.20
Q4) The mouth is where digestion begins.
A)True
B)False
Q5) Assign the code for hematemesis: __________
Q6) Name one purpose of the small intestine.
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Chapter 19: Diseases of the Skin and Subcutaneous Tissue
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Sample Questions
Q1) Which layer of the skin is composed of fibrous connective tissue?
A)Outer layer
B)Middle layer
C)Inner layer
D)None of the above
Q2) The outer layer of skin is called the ____________________.
Q3) What is excisional debridement?
Q4) 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
Q5) Nail horn,left thumb: __________
Q6) Another name for a pressure ulcer is a decubitus ulcer.
A)True
B)False
Q7) How is cellulitis treated?
Q8) Solar photosensitivity: __________
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) What does the abbreviation SLE stand for?
Q2) The patient was admitted with disc herniation at L4-L5.The patient has failed conservative treatments such as physical therapy.NSAIDs and even steroid injections did not provide much relief.The patient was taken to surgery,and an open discectomy was performed.The patient recovered uneventfully and was discharged.Instructions were given to avoid lifting anything heavier than 10 pounds until after the postoperative clinic visit.
Final Diagnosis: Herniated disc.
Procedure: Discectomy (partial).
A)M51.27,0ST40ZZ
B)M51.06,0ST20ZZ
C)M51.25,0SB40ZZ
D)M51.26,0SB20ZZ
Q3) ____________________ is a metabolic bone disorder that results in decreased bone mass and density.
Q4) Right plantar fasciitis (right): __________
Q5) What does the abbreviation AKA stand for?
Q6) Calcification of lumbar disc: __________
27
Q7) Ankylosis of right shoulder: __________
Q8) Staphylococcal pyogenic arthritis of left knee: __________
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) Inflammation of the prostate that can be either acute or chronic in nature resulting from bacteria or inflammation not caused by bacteria
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) In ICD-10-CM,there is a code to identify postprocedural renal failure.
A)True
B)False
Q3) 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
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Chapter 22: Pregnancy, childbirth, and the Puerperium
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Sample Questions
Q1) A woman pregnant at 43 weeks is still considered to be a term pregnancy.
A)True
B)False
Q2) 35 or older at date of delivery
A)Young obstetric patient
B)Antepartum
C)Primigravida
D)Puerperium
E)Gravid
F)Elderly OB patient
Q3) Ectopic pregnancies occur in 1 in ____ pregnancies.
A)10
B)25
C)50
D)100
Q4) In ICD-10-CM the diagnosis used for an elective abortion comes from the pregnancy chapter.
A)True
B)False
Q5) The process of milk production is ______________________.
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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) What does AGA stand for?
Q2) If the baby scores a ____ or higher on the Apgar test 1 minute after birth,he or she is considered to be healthy.
A)1
B)5
C)7
D)3
Q3) What is the most common treatment for infants with moderate jaundice?
Q4) Which of the following is true of Chapter 16 codes?
A)Chapter 16 codes are never for use on the maternal record.
B)Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
C)Chapter 16 codes generally should be sequenced as the principal diagnosis on the newborn record,except the birth record,where the Z38 code is assigned.
D)All of the above are true.
Q5) Cesarean delivery at term with infant in fetal distress during labor: __________
Q7) What does LGA stand for? Page 31
Q6) Cesarean delivery at term of interlocking twins,Twin A: __________
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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) A(n)____________________ is a partial or completed dislocation.
Q2) When air or gas bubbles get into the bloodstream,this is called a(n)___________________.
Q3) When the bone is somewhat bent and partially broken;usually occurs in children
A)Crush injury
B)Fissured fracture
C)Comminuted fracture
D)Greenstick fracture
E)External skeletal fixation
F)Contusion
Q4) Upper limb amputation status-below elbow
A)Z94.6
B)Z89.211
C)Z89.432
D)Z87.820
E)Z91.81
Q5) Anaphylactic shock due to ingestion of milk: __________
Q6) A break in a bone is called a(n)____________________.
Q7) When a patient is unable to respond to people or to other stimuli,he or she is considered to have ____________________. Page 33
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) During hospital stay,in the patient's room,the nurse accidentally administered insulin,and this caused hypoglycemia;patient is not a diabetic,and no insulin was ordered: __________
Q2) First- and second-degree burn of face due to gas flame from stove in kitchen at patient's house while cooking: __________
Q3) Counseling for victim of child abuse (nonparental)
A)Z69.020
B)Z88.8
C)Z91.030
D)Z88.7
E)Z91.010
F)Z91.89
G)Z91.011
H)Z91.410
Q4) A patient combined prescription Percodan with beer and became stuporous and drowsy.
A)T40.2x1A,T51.0x1A,R40.1,R40.0
B)T40.2x1D,T51.0x1D,R40.1,R40.0
C)T40.2x1S,T51.0x1S,R40.1,R40.0
D)T40.2x1A,T51.0x1A
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Chapter 26: Complications of Surgical and Medical Care
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48 Verified Questions
48 Flashcards
Source URL: https://quizplus.com/quiz/43725
Sample Questions
Q1) 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
Q2) Patient with decreased visual acuity due to corneal graft rejection.Admitted for cadaver keratoplasty (external)of the left eye with removal of the previous corneal graft
A)T86.840,Y83.0,H54.7,08R9XKZ
B)T85.318A,Y83.0,H54.7,08R93KZ
C)T86.840,Y83.0,H54.7,08R83KZ
D)T86.841,Y83.0,H54.7,08R8XKZ
Q3) Patient had an outpatient surgical procedure this morning and was discharged in stable condition.Patient returns because of inability to void.A Foley catheter is inserted. Diagnosis: Postoperative urinary retention.
A)R33.8,R33.9,Y84.9,0T9B80Z
B)N99.89,R33.9,Y83.9,Y83.9,0T9B70Z
C)N99.0,R33.9,Y84.9,0T9B80Z
D)R33.8,R33.9,Y83.9,0T9B70Z
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