Introduction to Health Information Technology
Pre-Test Questions
Course Introduction
Introduction to Health Information Technology provides an overview of how information systems and technologies are used in healthcare to improve patient care, enhance operational efficiency, and support clinical decision-making. The course covers foundational concepts such as electronic health records (EHRs), health data standards, privacy and security regulations (like HIPAA), data management, and health informatics. Students will explore how health information technology impacts the healthcare industry, including emerging trends, key terminologies, and challenges in implementation. Through real-world examples and case studies, learners will develop an understanding of the crucial role of HIT professionals in modern health care environments.
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) What are the three items that the Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services?
A)personal care items
B)deductibles, drug costs, personal care items
C)premiums
D)deductibles, premiums, and coinsurance
Answer: D
Q2) Automatic coverage when age 65
A) Part A
B) Part D
C) Part B
Answer: A
Q3) The ____________________ program was developed by Congress to monitor the necessity of hospital admissions and review the treatment costs and medical records of hospitals.
Answer: qio
Qio
QIO
Q4) List the three components of the relative value unit. Answer: (in any order) work, overhead, malpractice
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Chapter 2: An Overview of ICD-10-CM
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Q1) There are 21 chapters in the ICD-10-CM.
A)True
B)False
Answer: True
Q2) All ICD-10-CM codes have seven characters.
A)True
B)False Answer: False
Q3) The National Center for Health Statistics is responsible for developing the procedure classification ICD-10-PCS.
A)True
B)False
Answer: False
Q4) This maps ICD-9-CM codes to ICD-10-CM codes:
A)Index
B)Tabular
C)multiaxial
D)GEMs
Answer: D
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Chapter 3: ICD-10-CM Outpatient Coding and Reporting
Guidelines
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Sample Questions
Q1) A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition. The primary diagnosis would be the medical condition that led to the admission.
A)True
B)False
Answer: True
Q2) Screening colonoscopy for colon cancer.
ICD-10-CM Code: ___________________
Answer: Z12.11
Q3) Long-term (current) use of aspirin.
ICD-10-CM Code: ___________________
Answer: Z79.82
Q4) A multigravida 48-year-old patient presents for routine prenatal visit, first trimester. No complications are noted.
ICD-10-CM Code: ___________________
Answer: O09.521
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 a pathological fracture of the left femur, due to neoplastic bone disease initial encounter:
A)S72.115A
B)S72.114A
C)M84.552A, D49.2
D)M84.551A, D49.2
Q2) Assign codes as directed in the Index, only after verifying the code in the Tabular. A)True
B)False
Q3) Right and left inguinal hernia.
ICD-10-CM Code:____________________
Q4) A late effect is the residual effect after the acute phase of an illness or injury has passed.
A)True
B)False
Q5) Multiple codes are often required for late effects, complication codes, and obstetric codes.
A)True
B)False
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Chapter 5: Introduction to CPT
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Q1) The two-digit modifier used by an Ambulatory Surgery Center (ASC) or hospital outpatient unit for a discontinued procedure prior to the administration of anesthesia is
Q2) The index of the CPT manual is in alphabetic order with the __________ __________ listed first and then further divided by subterm.
Q3) 3xxxx Laryngoscopy, indirect (separate procedure); diagnostic 3xxxx with biopsy
3xxxx with removal of foreign body
3xxxx with vocal cord injection
A) description of extent of service
B) alternative anatomic site
C) alternative procedure
Q4) Stenger Test
A)See Uroflowmetry
B)See Audiologic Function Test; Ear, Nose, and Throat
C)See Lipoprotein, Blood
Q5) According to the CPT Surgery Guidelines, what is the code for the following unlisted procedures: Unlisted procedure, neck or thorax?
Code: ____________________
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Chapter 6: Introduction to Level II National Codes HCPSC
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Q1) What is the HCPCS Level II code for Injection, gadoterate meglumine, 0.1 ml?
Q2) G codes are used to identify:
A)Professional procedures and services that would otherwise be reported with a CPT code but no CPT code has been established
B)The use of durable medical equipment
C)Drugs, biologicals, and types of medical equipment/services which are not identified by Level II National codes
D)The drugs administered and the amount or dosage given
Q3) A modifier:
A)subtracts from the definition of the code
B)adds to the HCPCS code number
C)provides additional information to the third-party payer
D)increases third-party payer reimbursement
Q4) What types of codes are not recognized by Medicare and other federal payers but may be useful for claims to some private payers?
A)L codes
B)S codes
C)J codes
D)G codes
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Chapter 7: Modifiers
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Q1) Modifier -57, decision for surgery, is used on what type of service?
A)E/M
B)surgery
C)anesthesia
D)all of the above
Q2) Modifier -59, distinct procedure service, is used to indicate that:
A)services that are usually bundled into one payment were provided as separate services
B)a subsequent surgery was planned or staged
C)a service was repeated
D)a patient is taken back to the operating room for surgical treatment of a complication resulting from a previous surgery
Q3) Modifier -80, Assistant Surgeon, is used when:
A)two surgeons perform a distinct part of the surgery
B)the surgery is complex and requires several physicians
C)a second surgeon provides assistance to the primary surgeon
D)all of the above
Q4) Modifier ______ is used to indicate that services of an outside laboratory were used.
Q5) ____________________ lists some HCPCS modifiers in the CPT book.
Page 9
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Chapter 8: Evaluation and Management EM Services
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Q1) A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
CPT Code: ____________________
Q2) What are the four levels of history type?
Q3) Complete the following blanks that refer to the three factors that the coder must consider in the assignment. ____________________ of service, ____________________ of service, ____________________ status
Q4) 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: ____________________
Q5) The code range for Home Services is ____________________.
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Chapter 9: Anesthesia
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Q1) Anesthesia services include postoperative visits to the patient by the anesthesiologist.
A)True
B)False
Q2) ____________________ of the CPT manual lists some HCPCS modifiers.
Q3) Assign a CPT anesthesia code for debridement of third-degree burns of right arm, 6% body surface area.
CPT Code: ____________________
Q4) Assign a CPT anesthesia code for repair of cleft palate. CPT Code: ____________________
Q5) Codes for Qualifying Circumstances are located in both the Anesthesia Guidelines and the ____________________ section of the CPT manual.
Q6) In the Anesthesia section of the CPT manual, the codes are usually divided first by which of the following?
A)specific procedure
B)anatomic site
C)degree of difficulty
D)amount of time
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Chapter 10: Surgery Guidelines and General Surgery
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Q1) Services
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
Q2) CPT Surgical Package Definition
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) This information is placed after some codes in the CPT manual and contains helpful information.
A)parenthetical information
B)Guidelines
C)index locations
D)bracketed information
Q4) Third-party payers determine the contents of a surgical package.
A)True
B)False
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Chapter 11: Extension 1: Chapter-Specific Guidelines:
ICD-10-CM Chapters 1-10
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Sample Questions
Q1) Primary malignancy of the left tonsil.
ICD-10-CM Code: ____________________
Q2) Sick sinus syndrome.
ICD-10-CM Code: _____________________
Q3) COPD with acute exacerbation.
ICD-10-CM Code: _____________________
Q4) If a patient is admitted for dehydration due to chemotherapy, the dehydration is the first-listed diagnosis.
A)True
B)False
Q5) Hypertensive congestive heart failure with hypertension and chronic kidney disease, stage 4.
ICD-10-CM Codes: ____________________, ___________________,
Q6) The Eustachian tube is part of the inner ear.
A)True
B)False
Q7) Malignant hypertension with stage 4 chronic kidney disease.
ICD-10-CM Codes: ____________________, ____________________
Q8) Otomycosis due to aspergillosis. Page 13
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Chapter 13: Musculoskeletal System
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Q1) A ____ arthroscopy is always included in a surgical arthroscopy.
A)biopsy
B)separate procedure
C)diagnostic
D)debridement
Q2) ____________________ is the application of pulling force to hold a bone in correct alignment.
Q3) 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): ____________________
Q4) You cannot report codes for open wound exploration (20100-20103) if the wound is sufficient in size to accomplish the repair and the wound does not need to be enlarged. A)True
B)False
Q5) Using codes from the wound exploration category requires the coder to assess the extent of the procedure.
A)True
B)False
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Chapter 14: Integumentary System
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Sample Questions
Q1) When reporting a staged procedure what modifier is added to the CPT code?
A)-25
B)-51
C)-58
D)-76
Q2) An excision of a benign lesion from the neck measuring 1.8 cm:
A)11422
B)11200
C)11307
D)11622
Q3) Which modifier indicates a significant, separately identifiable E/M service?
A)-25
B)-51
C)-50
D)-47
Q4) Mastectomy that is done for gynecomastia:
A)19300
B)19301
C)19303
D)19305
Page 16
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Chapter 14: Respiratory System
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Sample Questions
Q1) Jennifer Prescott, age 47, has developed chest pain and difficulty breathing. Jennifer has had several episodes of coughing up thick blood-tinged sputum. A diagnostic bronchoscopy is performed, with a specimen taken of the bronchial mass. The pathology report is positive for carcinoma.
CPT Code: ____________________
Q2) The physician uses an endoscope for a diagnostic evaluation of the nose. A polyp is identified and removed using forceps.
CPT Code: ____________________
Q3) A surgical sinus endoscopy includes a sinusotomy (when appropriate) and diagnostic endoscopy.
A)True
B)False
Q4) Endoscopic lobectomy of a single lobe.
CPT Code: ____________________
Q5) A physician performs an emergency transtracheal tracheostomy to remove a foreign object.
CPT Code: ____________________
Q6) Excision of tracheal tumor using cervical approach. CPT Code: ____________________
Page 17
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Chapter 15: Extension 2: Chapter-Specific Guidelines:
ICD-10-CM Chapters 11-14
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Q1) Boil on the face, due to Staphylococcus epidermidis.
ICD-10-CM Codes:_____________________, _____________________
Q2) Acute pseudo-obstruction of the intestine.
ICD-10-CM Code:_____________________
Q3) Choledochoduodenal fistula.
ICD-10-CM Code:_____________________
Q4) For hemorrhage to be reported, there does not have to be active bleeding; however, there must be documentation in the medical record indicating active bleeding has occurred and the source of the bleeding must be identified.
A)True
B)False
Q5) Patient seen by rheumatologist for rheumatoid arthritis of the right elbow with leukopenia and splenoadenomegaly (Felty's syndrome).
ICD-10-CM Code:____________________
Q6) There are only two code categories assigned to report infectious arthropathies: M00 and M01.
A)True
B)False
Page 18
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Chapter 16: Cardiovascular System
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Q1) Selective catheterization of both renal arteries. The right femoral artery was entered by Seldinger technique, and a 6-French sheath was placed. No heparin was used. The patient had a BP of over 200 systolic. After placement of the 6-French sheath, a pigtail catheter was introduced and an aortogram was done in the AP projection using 20 cc of dye. Next a 5-French Cobra catheter was introduced, and both the left renal artery and the right renal artery were selectively opacified. The patient was sent to her room in good condition without complications after renal angiograms had been done, the sheath had been removed, and hemostasis had been secured.
Results: Right renal artery-there is a single right renal artery with a minimal irregularity along the wall, but no evidence of significant fibromuscular dysplasia or stenosis is noted. The distal nephrogram appears unremarkable.
Left renal artery-there are two renal arteries, the upper pole renal artery rising in the normal location and the lower pole renal artery considerably lower. Both these vessels appear relatively unremarkable with no stenosis or fibromuscular dysplasia seen either. CPT Code: (Surgery Code) ____________________
Q2) Venous bypass graft for occlusive disease, femoral-popliteal.
CPT Code: ____________________
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Chapter 17: Hemic, Lymphatic, Mediastinum, and Diaphragm
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Q1) The mediastinum category code range is ____________________.
Q2) Imbrication of the diaphragm for eventration, transabdominal, nonparalytic.
CPT Code: ____________________
Q3) Imbrication
A) Overlapping
B) Grafting tissue from one source to another
C) Inflammation of lymph nodes
D) Cutting into the mediastinum
Q4) The mediastinum is located between the lungs.
A)True
B)False
Q5) How many categories are located in the Mediastinum subheading?
A)4
B)3
C)6
D)2
Q6) The physician performs an extensive drainage of a lymph node abscess.
CPT Code: ____________________
Q7) Resection of a mediastinal tumor.
CPT Code: ____________________ Page 20
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Chapter 18: Digestive System
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Q1) With the exception of incisional and ventral hernias, the use of mesh or other prosthesis is not separately reported when performing hernia repairs.
A)True
B)False
Q2) For a fine-needle aspiration of the salivary gland, the correct code would be 42400.
A)True
B)False
Q3) When coding 44701, it is necessary to add a modifier -51.
A)True
B)False
Q4) Exploration of abdominal and pelvic cavities
A) Colonoscopy
B) Proctosigmoidoscopy
C) Sigmoidoscopy
D) Laparoscopy
Q5) Excision, lesion of the palate with a simple primary closure. CPT Code: ____________________
Q6) The gallbladder is removed under laparoscopic guidance. CPT Code: ____________________
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Chapter 19: Urinary and Male Genital Systems
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Q1) Removal of the prostate
A) Prostatectomy
B) Retroperitoneal
C) Nephrectomy
D) Manometric study
E) Bladder aspiration
F) Calculus
Q2) Test to measure kidney and ureter flow and pressure
A) Prostatectomy
B) Retroperitoneal
C) Nephrectomy
D) Manometric study
E) Bladder aspiration
F) Calculus
Q3) The term that describes the study of the motion and flow of urine is:
A)urology
B)urinology
C)urodynamics
D)urofunction
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Chapter 20: Reproductive, Intersex Surgery, Female Genital
System, and Maternity Care and Delivery
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Q1) Introduction of saline into tubes/ovaries to determine patency
A) Hysterosonography
B) LEEP
C) Prostaglandin
D) VBAC
E) Cerclage
Q2) Incision and drainage of these glands are not reported using Female Genital System codes but are instead reported using Surgery section, Urinary System codes.
A)Skene's
B)Bartholin's
C)Weber's
D)Virchow's
Q3) Suturing of uterine cervix
A) Hysterosonography
B) LEEP
C) Prostaglandin
D) VBAC
E) Cerclage
Q4) Catheterization and introduction of contrast for a hysterosalpingography. CPT Code: ____________________
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Chapter 21: Extension 3: Chapter-Specific Guidelines :
ICD-10-CM Chapters 15-21
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Q1) Lethargy.
ICD-10-CM Code: ____________________
Q2) Heart murmur.
ICD-10-CM Code: ____________________
Q3) Congenital dislocatable hip.
ICD-10-CM Code: ____________________
Q4) Complete traumatic amputation of left arm, below the elbow, subsequent encounter.
ICD-10-CM Code: ____________________
Q5) Fever, unknown origin.
ICD-10-CM Code: ____________________
Q6) Metabolic acidemia in newborn, noted at birth.
ICD-10-CM Code: _____________________
Q7) Codes from Chapter 16, the perinatal codes, should be used on the mother's record to identify fetal conditions.
A)True
B)False
ICD-10-CM Code: ____________________ Page 25
Q8) Pulmonary embolism following incomplete spontaneous abortion.
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Chapter 22: Endocrine and Nervous Systems
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Q1) What procedure is often performed with a laminectomy?
A)discectomy
B)corpectomy
C)arthrodesis
D)creation of a shunt
Q2) Burr hole
A) method of identifying a specific area or point in the brain
B) removal of a portion of the skull
C) a small opening in the skull
D) an incision of the skull
Q3) Destruction of infraorbital nerve with neurolytic agent.
CPT Code: ____________________
Q4) Diagnostic lumbar spinal puncture.
CPT Code: ____________________
Q5) Shunts are devices used to:
A)relieve pressure in the brain caused by fluid buildup
B)monitor currents emanating from the brain
C)decompress spinal nerves
D)none of the above
Q6) Name the four glands represented in the Endocrine subsection.
Page 27
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Chapter 23: Eye, Ocular Adnexa, Auditory, and Operating Microscope
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Q1) Removal of impacted cerumen from both ears using wax curettes and suction. CPT Code: ____________________
Q2) Sclera lesion excision, left eye.
CPT Code: ____________________
Q3) Bilateral repair of blepharoptosis with frontalis muscle technique.
CPT Code: ____________________
Q4) The destruction codes in the Posterior Segment subsection include one or more sessions.
A)True
B)False
Q5) The codes in the Eye and Ocular Adnexa subsection are bilateral codes.
A)True
B)False
Q6) Cataract and lens replacement uses ____ different approaches.
A)3
B)2
C)4
D)1
CPT Code: ____________________ Page 28
Q7) Otoplasty of the right ear, with size reduction.
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Chapter 24: Radiology Section
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Q1) X-rays, two views per side, mastoids.
CPT Code: ____________________
Q2) Noninvasive diagnostic technique that produces a cross-sectional image of organs and other internal body structures
A)venography
B)lymphangiography
C)magnetic resonance
D)myelogram
E)cholangiography
F)computed tomography
G)angiography
H)pelvimetry
I)ultrasound
J)tomography
Q3) Selective spinal angiography, supervision and interpretation.
CPT Code: ____________________
Q4) There are four subheadings in the Radiology section.
A)True
B)False
Q5) ____________________ means lying down.
Page 30
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Chapter 25: Pathology/Laboratory Section
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Q1) 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
Q2) Pathologists have specific codes for clinical pathology consultations.
A)True
B)False
Q3) A wet mount to determine a vaginal yeast infection using a KOH prep.
CPT Code: ____________________
Q4) During the evocative suppression testing, the correct codes for the physician's administration of the evocative or suppressive agents are reported depending on the method of administration.
A)True B)False
Q5) Chemistry test for gases, blood, and O<sub>2</sub> saturation only by direct measurement.
CPT Code: ____________________
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Chapter 26: The Medicine Section
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Q1) measles, mumps, and rubella vaccine
A)DtaP
B)IPV
C)HBIg
D)OPV
E)DT
F)HiB
G)MMRV
H)MMR
I)Td
J)DTP
Q2) The Cardiovascular subsection contains many diagnostic/therapeutic procedures and services that are primarily divided as to whether the procedures or services are invasive or:
A)selective
B)random
C)noninvasive
D)secondary
Q3) Simple pulmonary stress test.
CPT Code: ____________________
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Chapter 27: Inpatient Coding
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Q1) Patient is admitted with epigastric pain due to acute pancreatitis.
Q2) The root operation that is defined as correcting a portion of a previously performed procedure is:
A)revision of device in
B)replacement
C)reposition
D)transfer
Q3) Patient was discharged with a diagnosis of probable myocardial infarction.
Q4) In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.
A)True
B)False
Q5) The root operation that is defined as cutting out or off, without replacement, all of a body part is:
A)restriction
B)reposition
C)resection
D)revision of device in
Q6) Patient was admitted with shortness of breath and edema due to decompensation of congestive heart failure.
Page 33
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