Introduction to Health Informatics
Chapter Exam Questions
Course Introduction
Introduction to Health Informatics provides students with a foundational understanding of how information technology is applied within healthcare environments to improve patient outcomes, enhance healthcare delivery, and support research. The course covers key concepts such as electronic health records (EHRs), health information systems, data standards, healthcare interoperability, privacy and security, and the role of informatics in public health and clinical decision-making. Students will explore real-world applications, emerging technologies, and ethical considerations inherent in managing sensitive health data, preparing them for further study or entry-level roles in the rapidly evolving field of health informatics.
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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Q1) QIO ________________________________________
Answer: Quality Improvement Organizations
Q2) CMS handles the daily operation of the Medicare program through the use of ____ ____ ____, formerly Fiscal Intermediaries.
A)Medical Adjustment Contractor
B)Medicare Administrative Cooperative
C)Medicare Administrative Contractors
D)Medical Administrative Contractors
Answer: C
Q3) For endoscopic procedures, Medicare allows the full value of the highest valued endoscopy, plus the difference between the next highest endoscopy and the ____________________ endoscopy.
Answer: highest
Q4) This program is also known as Medicare Advantage.
A)Part A
B)Part B
C)Part C
D)Part D
Answer: C
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Chapter 2: An Overview of ICD-10-CM
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Q1) Which organization has been responsible for the development of ICD-10-CM?
A)NCHS
B)AHIMA
C)AMA
D)AHA
Answer: A
Q2) ICD-10-CM codes are alphanumeric, with all codes beginning with a number.
A)True
B)False
Answer: False
Q3) ICD-10-CM codes have a maximum of five characters.
A)True
B)False
Answer: False
Q4) The I-10 has instructional notations to provide guidance.
A)True
B)False
Answer: True
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Chapter 3: ICD-10-CM Outpatient Coding and Reporting
Guidelines
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Q1) If the pre- and postoperative diagnoses are different, the preoperative diagnosis should be reported.
A)True
B)False
Answer: False
Q2) Screening for respiratory tuberculosis.
ICD-10-CM Code: ___________________
Answer: Z11.1
Q3) 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
Q4) Z codes cannot be used in the outpatient setting.
A)True
B)False Answer: False
Q5) Long-term (current) use of systemic steroids. ICD-10-CM Code: ___________________
Answer: Z79.52
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Chapter 4: Using ICD-10-CM
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Sample Questions
Q1) The correct reporting for acute cholecystitis with cholelithiasis with obstruction:
A)K80.19
B)K80.12
C)K80.10
D)K80.01
Q2) Pseudocyst of the pancreas.
ICD-10-CM Code:____________________
Q3) Right and left inguinal hernia.
ICD-10-CM Code:____________________
Q4) Acute and chronic systolic (congestive) heart failure.
ICD-10-CM Code:____________________
Q5) Aphasia and cognitive defects, as a result of nontraumatic intracranial hemorrhage.
ICD-10-CM Codes:____________________, ____________________
Q6) Hypertensive heart disease NOS.
ICD-10-CM Code:____________________
Q7) Subsequent encounter for a joint injection for a patient with acute pain due to a sprained right acromioclavicular joint.
ICD-10-CM Codes:____________________, _____________________
Page 6
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Chapter 5: Introduction to CPT
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Q1) According to the Radiology Guidelines, these are the methods that qualify as "with contrast."
A)intravascularly, intra-articularly, intrathecally
B)oral, rectal, intramuscular
C)other route, intravascularly, intrathecally
D)intra-articularly, intravenously, interarticularly
Q2) Which of the following represents three of the six elements that a special report must contain?
A)condition, service, description
B)anatomic site, service, extent
C)nature, extent, need
D)service, extent, procedure
Q3) According to the CPT manual, modifier -91 is not to be used when tests are ____ to confirm initial results.
A)ordered
B)rerun
C)directed
D)selected
Q4) 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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Q1) According to the notes preceding the Category III codes in the CPT manual, the digits of the Category III codes are not intended to reflect the placement of the code in the Category I section of the CPT:
A)heading
B)subsection
C)nomenclature
D)category
Q2) Level II National Modifiers are located in the introduction section of the HCPCS and also in Appendix A of CPT.
A)True
B)False
Q3) Level II National Modifiers are found in the introduction section of HCPCS and also in what Appendix of CPT?
A)Appendix A
B)Appendix B
C)Appendix C
D)Appendix D
Q4) What is the HCPCS Level II code for Injection, gadoterate meglumine, 0.1 ml?
Q5) Chemotherapy drugs J9000-J9999 include the ____________________ of the drug.
8
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Chapter 7: Modifiers
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Q1) 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? ____________________
Q2) What modifier would you use if you were coding only the technical component of a diagnostic procedure? ____________________
Q3) The modifier that indicates multiple procedures is:
A)-32
B)-51
C)-22
D)-26
Q4) Mrs. Smith presented to her physician's office for an office visit for an upper respiratory infection. The physician examines the patient and prescribes antibiotics. The physician notices the patient has a suspicious-looking mole. The physician examined the mole and determined that it should be removed. The mole was removed during the same office visit. The physician bills both an E/M code and a procedure code. Which modifier would you use on the E/M code? ____________________
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Chapter 8: Evaluation and Management EM Services
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Q1) The _______________ is a statement describing the reason for the encounter and is a history element.
Q2) An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.
CPT Code: ____________________
Q3) A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101<sup>\(\circ\)</sup> F yesterday. Mom treated her with Tylenol. The fever this AM is 99<sup>\(\circ\)</sup> F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, lungs, and heart. Vital signs were taken in the office. The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic. The MDM is stated to be moderate.
CPT Code: ____________________
Q4) Modifier ____________________ is used to indicate that a separately identifiable E/M service was performed by the same individual on the same day as the preventive medicine service.
Q5) What are the four elements of history?
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Chapter 9: Anesthesia
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Q1) Anesthesia for diagnostic arthroscopic procedure of the knee joint.
CPT Code: ____________________
Q2) Anesthesia for bilateral vasectomy.
CPT Code: ____________________
Q3) Only one CPT procedure code may be represented by one anesthesia code.
A)True
B)False
Q4) Codes for Qualifying Circumstances are located in both the Anesthesia Guidelines and the ____________________ section of the CPT manual.
Q5) The modifier "-AA" is an example of what type of modifier?
A)CPT
B)HCPCS
C)ICD-10-CM
D)None of the above
Q6) Concurrent modifiers are used to describe:
A)number of cases an anesthesiologist is directing or supervising at one time
B)services provided by multiple physicians on the same day
C)multiple services provided on the same day
D)none of the above
Q7) ____________________ of the CPT manual lists some HCPCS modifiers.
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Chapter 10: Surgery Guidelines and General Surgery
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Q1) Local anesthesia is defined in the CPT guidelines as:
A)local infiltration
B)metacarpal/digital block
C)topical anesthesia
D)all of the above
Q2) Supplied Materials
A)Evaluating the patient in the postanesthesia recovery area
B) Special Services and Reports are presented in the Medicine Section
C)List drugs, trays, supplies, and materials provided
D)Complexity of service
Q3) 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
Q4) Parenthetical phrases that sometimes follow a code or code group provide further information about codes that may be applicable.
A)True
B)False
Page 12
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Chapter 11: Extension 1: Chapter-Specific Guidelines:
ICD-10-CM Chapters 1-10
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Q1) If the type of diabetes mellitus is not documented in the medical record, the default is type 2 diabetes mellitus.
A)True
B)False
Q2) The Eustachian tube is part of the inner ear.
A)True
B)False
Q3) Encounter for screening for HIV due to high-risk heterosexual behavior.
ICD-10-CM Codes: _____________________, _____________________
Q4) Acute rheumatic mitral and aortic valve disease.
ICD-10-CM Code: ____________________
Q5) Unspecified thyrotoxicosis with thyrotoxic storm.
ICD-10-CM Code: _____________________
Q6) Acute lower respiratory infection (Streptococcus, group A) in a patient with COPD.
ICD-10-CM Codes: ____________________, ____________________,
Q7) Pleural plaque without asbestos.
ICD-10-CM Code: ____________________
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Chapter 13: Musculoskeletal System
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Q1) Using codes from the wound exploration category requires the coder to assess the extent of the procedure.
A)True
B)False
Q2) Surgical and fracture repair codes in the musculoskeletal subsection:
A)include the application and removal of all casts, splints, and strapping
B)include the application and removal of the initial casts, splints, or strapping applied by the treating physician
C)include the application and removal applied by an urgent care/emergency room physician when the urgent care/emergency room physician is not providing the fracture care
D)do not include casts, splints, or strapping, therefore allowing the physician to charge separately for these services
Q3) ____________________ is the application of pulling force to hold a bone in correct alignment.
Q4) Closed treatment of second and third metatarsal fractures of the left foot, with manipulation. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
CPT Code(s): ____________________
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Chapter 14: Integumentary System
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Q1) The removal of a lesion by transverse incision that did not require sutured closure is reported using codes from which subsection?
A)Removal of Skin Tags
B)Biopsy
C)Paring or Cutting
D)Shaving of Epidermal or Dermal Lesions
Q2) Simple repair of a superficial wound of the nose measuring 5.2 cm.
CPT Code: ____________________
Q3) Suture of superficial wounds of cheek: one 1-cm laceration, one 3-cm laceration, and one 2-cm laceration.
CPT Code: ____________________
Q4) A physician performs an operative procedure that has a 90-day surgical package. On day 40, the same physician performs an unrelated procedure on the same patient. What modifier would you attach to the CPT code when reporting the second procedure?
A)-24
B)-25
C)-58
D)-79
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Chapter 14: Respiratory System
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Q1) The term that describes obtaining a tissue sample is:
A)laser
B)ablation
C)biopsy
D)incision
Q2) Reshaping of the nasal septum to correct airway obstruction.
CPT Code: ____________________
Q3) Lavage
A)removal by cutting
B)washing out an organ
C)destruction of tissue by burning
D)free flow or withdrawal of fluids
Q4) Three-year-old Hannah is playing with a marble and sticks it in her nose. Her mother is unable to dislodge the marble so she takes Hannah to the physician's office. The physician removes the marble with hemostats.
CPT Code: ____________________
Q5) All "sinus" codes are reported as bilateral procedures only.
A)True
B)False
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Chapter 15: Extension 2: Chapter-Specific Guidelines:
ICD-10-CM Chapters 11-14
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Q1) Mucinosis of the skin.
ICD-10-CM Code: _____________________
Q2) For certain conditions, the bone may be affected at the upper or lower end such as with avascular necrosis of the femur in the knee joint. When the site is at the joint, report the condition of the joint, not the bone.
A)True
B)False
Q3) Dyskinesia of esophagus.
ICD-10-CM Code:_____________________
Q4) Acute hematogenous osteomyelitis of the right hand, due to Streptococcus, group A.
ICD-10-CM Codes:____________________, ____________________
Q5) Itching.
ICD-10-CM Code:____________________
Q6) With indirect infections (Category M02) of joints due to infectious or parasitic disease classified elsewhere, the coder is directed to "code first" the underlying disease. A)True
B)False
Page 17
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Chapter 16: Cardiovascular System
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Q1) Code 36000 (Introduction of needle or intracatheter, vein) is an example of:
A)selective catheterization
B)nonselective catheterization
C)injection procedure
D)none of the above
Q2) Coronary artery bypass using two arterial grafts.
CPT Code: ____________________
Q3) Cardioversion.
Reason for procedure: Atrial fibrillation.
Elective, external 175 J of synchronous cardioversion was undertaken very easily, with complete resolution of atrial fibrillation to normal sinus rhythm.
CPT Code: ____________________
Q4) Which of the following modifiers does NOT identify a coronary artery?
A)-RC
B)-LC
C)-LD
D)-MC
Q5) Cardiopulmonary resuscitation.
CPT Code: ____________________
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Chapter 17: Hemic, Lymphatic, Mediastinum, and Diaphragm
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Q1) This bone marrow is taken from a close relative, so there is a genetic similarity.
A)allogeneic
B)transgenic
C)autologenic
D)biogenic
Q2) What is it called when the diaphragm is out of normal position and has moved up farther into the thoracic cavity?
A)hernia
B)eventration
C)imbriation
D)laceration
Q3) This type of lymphadenectomy is the removal of the lymph nodes, glands, and surrounding tissues.
A)modified
B)radical
C)limited
D)partial
Q4) Suprahyoid lymphadenectomy.
CPT Code: ____________________
19
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Chapter 18: Digestive System
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Q1) Plastic repair of the cleft lip/nasal deformity primary bilateral, one of two stages.
CPT Code: ____________________
Q2) The destruction by electrosurgery of fourteen papilloma lesions in the anal area.
CPT Code: ____________________
Q3) What two words are important factors in coding hernia repair?
A)incarcerated/strangulated
B)open/closed
C)hemorrhage/nonhemorrhage
D)definitive/exploratory
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) Transection of the esophagus with repair for esophageal varices.
CPT Code: ____________________
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Chapter 19: Urinary and Male Genital Systems
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Q1) Radical orchiectomy by inguinal approach due to a tumor.
CPT Code: ____________________
Q2) When urodynamics are performed and the physician only interprets the results, the correct modifier would be:
A)-79
B)-26
C)-TC
D)-54
Q3) The patient had a 3.8 cm testicular laceration repair from a baseball injury.
CPT Code: ____________________
Q4) A radical retropubic prostatectomy with nerve sparing.
CPT Code: ____________________
Q5) When coding 51797 it is necessary to add a modifier -51.
A)True
B)False
Q6) Complex cystometrogram with calibrated electronic equipment.
CPT Code: ____________________
Q7) Urethromeatoplasty with mucosal advancement.
CPT Code: ____________________
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Chapter 20: Reproductive, Intersex Surgery, Female Genital
System, and Maternity Care and Delivery
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Q1) Diagnostic amniocentesis includes radiologic supervision and interpretation.
A)True
B)False
Q2) Lysis of adhesions is performed on either the fallopian tubes or the:
A)vagina
B)uterus
C)ovaries
D)vulva
Q3) Amniocentesis. Code only the procedure, not the radiological service.
CPT Code: ____________________
Q4) According to the text, vulvectomy codes are divided based on the ____ and extent of vulvar area removed during the procedure.
A)complexity
B)status (malignant or premalignant lesions)
C)size
D)recurrence
Q5) The patient presents with a perineal abscess of the vulva. The physician performs incision and drainage.
CPT Code: ____________________
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Chapter 21: Extension 3: Chapter-Specific Guidelines :
ICD-10-CM Chapters 15-21
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Q1) An adverse effect occurs when a drug has been correctly prescribed and properly administered and the patient develops a reaction.
A)True
B)False
Q2) Rupture of fallopian tube due to pregnancy.
ICD-10-CM Code: ____________________
Q3) Vitamin K deficiency of newborn.
ICD-10-CM Code: ____________________
Q4) Pulmonary embolism following incomplete spontaneous abortion.
ICD-10-CM Code: ____________________
Q5) Complete traumatic amputation of left arm, below the elbow, subsequent encounter.
ICD-10-CM Code: ____________________
Q6) Congenital cystic kidney disease.
ICD-10-CM Code: ____________________
Q7) The perinatal period extends from before birth through 28 days after birth.
A)True B)False
Q8) Heart murmur.
ICD-10-CM Code: ____________________ Page 23
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Chapter 22: Endocrine and Nervous Systems
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Q1) Anesthetic injection of sphenopalatine ganglion. CPT Code: ____________________
Q2) Destruction of infraorbital nerve with neurolytic agent. 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) Incision and drainage of an infected thyroglossal duct cyst. CPT Code: ____________________
Q6) What procedure is often performed with a laminectomy?
A)discectomy
B)corpectomy
C)arthrodesis
D)creation of a shunt
Q7) The physician drills a burr hole in the cranium to drain a subdural hematoma. CPT Code: ____________________
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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) Removal of a superficial foreign body in the external left eye. CPT Code: ____________________
Q3) Removal of impacted cerumen from both ears using wax curettes and suction. CPT Code: ____________________
Q4) The transparent part of the eye is the ____________________.
Q5) Strabismus surgery:
A)corrects the condition in which the refractive surfaces of the eye are unequal
B)removes the opaque covering on or in the lens
C)is a repair of the cornea
D)corrects the muscle misalignment
Q6) The destruction codes in the Posterior Segment subsection include one or more sessions.
A)True
B)False
Q7) The codes in the Eye and Ocular Adnexa subsection are bilateral codes.
A)True
B)False
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Chapter 24: Radiology Section
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Q1) CT scan of brain without contrast medium enhancement. CPT Code: ____________________
Q2) Unlisted ultrasound procedure.
CPT Code: ____________________
Q3) Follicular study, ultrasound of the pelvis nonobstetric, B-scan, and real time with image documentation follow-up.
CPT Code: _____________________
Q4) ____________________ means lying down.
Q5) One MeV intermediate radiation treatment, single treatment area. CPT Code: ____________________
Q6) Bilateral diagnostic mammography for a patient whose previous screening mammogram showed areas of suspicious infiltrate.
CPT Code: ____________________
Q7) Complete abdominal ultrasound using real time with image documentation. CPT Code: ____________________
Q8) There are four subheadings in the Radiology section. A)True B)False
Q9) Vitamin B<sub>12</sub> absorption study with intrinsic factor. CPT Code: ____________________ Page 27
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Chapter 25: Pathology/Laboratory Section
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Q1) A dipstick urinalysis for ketones. CPT Code: ____________________
Q2) Blood analysis for HGH. CPT Code: ____________________
Q3) A drug screening for methamphetamine, single class method. CPT Code: ____________________
Q4) Qualitative analysis is defined as:
A)determining the amounts and proportions of chemical constituents
B)analysis of a substance in order to ascertain the nature of chemical constituents
Q5) Codes in the Pathology/Laboratory section, Evocation/Suppression Testing include which of the following?
A)complete service
B)test, injection, substance administered, physician time
C)injection and substance administered
D)test only
Q6) Immunology codes are used to report conditions of the ____________________ system.
Q7) A wet mount to determine a vaginal yeast infection using a KOH prep. CPT Code: ____________________
29
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Chapter 26: The Medicine Section
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Q1) Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens for aphakia, both eyes.
CPT Code: ____________________
Q2) What is being measured while the sleep testing is being conducted?
A)settings
B)outline
C)baseline
D)parameters
Q3) Office visit codes may not be reported in addition to allergen immunotherapy codes even if other identifiable evaluation and management services are provided at the time of immunotherapy.
A)True
B)False
Q4) A 12-year-old presented for a diagnostic analysis of his cochlear implant including programming.
CPT Code: ____________________
Q5) Simple pulmonary stress test.
CPT Code: ____________________
Q6) The administration code for an influenza vaccine is ____________________.
Page 30
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Chapter 27: Inpatient Coding
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Q1) The root operation that is defined as freeing of a body part is:
A)release
B)repair
C)removal of device from
D)inspection
Q2) Patient is admitted with epigastric pain due to acute pancreatitis.
Q3) 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
Q4) The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.
A)True
B)False
Q5) Patient was admitted with severe diarrhea. The physician documents the discharge diagnosis as gastroenteritis versus food poisoning.
Q6) Patient was discharged with a diagnosis of probable myocardial infarction.
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