Introduction to Health Information Management Exam
Solutions
Course Introduction
Introduction to Health Information Management offers students an overview of the fundamental principles, roles, and practices involved in managing health information within healthcare organizations. The course explores key topics such as the structure and use of health data, electronic health records (EHRs), healthcare documentation standards, privacy and security regulations (including HIPAA), and the vital role of Health Information Management (HIM) professionals in ensuring information accuracy, confidentiality, and compliance. Students will gain insights into how technology transforms health information processes and the importance of data integrity in supporting clinical decision-making, patient care, and health system operations.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2017 Edition 1st Edition by Karla R. Lovaasen
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26 Chapters
1611 Verified Questions
1611 Flashcards
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Chapter 1: The Rationale for and History of Coding
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) Both AHIMA and AAPC have standards for ethical coding.
A)True
B)False
Answer: True
Q2) Without the __________ system the comparison of data would be impossible.
Answer: classification
Q3) Coded data are used for only one purpose.
A)True
B)False
Answer: False
Q4) AHA
A)American Academy of Professional Coders
B)Certified Coding Specialist
C)American Hospital Association
D)National Center for Health Statistics
E)Registered Health Information Technician
Answer: C
Q5) HIPAA stands for __________ of 1996.
Answer: Health Insurance Portability and Accountability Act
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Chapter 2: The Health Record As
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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) If the condition of a patient is being clinically evaluated,the coder would expect to see ____.
A)an admission date
B)letters
C)clinical observations
D)an operative report
Answer: C
Q3) How long after admission is it required by TJC that the admission history and physical be completed?
Answer: Within 24 hours
Q4) The reason,in the patient's own words,for presenting to the hospital is the _________________.
Answer: chief complaint
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Chapter 3: ICD-10-Cm Format and Conventions
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39 Flashcards
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Sample Questions
Q1) A block in ICD-10-CM is a range of categories.
A)True
B)False
Answer: True
Q2) __________,a form of punctuation,are used in the index to identify manifestation codes in the Alphabetic Index.
Answer: Brackets
Q3) The word(s)"____" should be interpreted to mean either "and" or "or" when it appears in the title.
A)with
B)see C)omit code
D)and Answer: D
Q4) What does NEC stand for?
Answer: Not elsewhere classifiable
Q5) The word "__________" in the Alphabetic Index is sequenced immediately following the main term,not in alphabetic order.
Answer: with
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Chapter 4: Basic Steps of Coding
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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) What is the main term in "calculus of the ureter"?
Q3) Exceptions to the general rule that main terms usually identify disease conditions are Z codes.
A)True
B)False
Q4) A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.
A)True
B)False
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Chapter 5: General Coding Guidelines for Diagnosis
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Sample Questions
Q1) What is the diagnosis code(s)for memory deficit due to previous cerebral infarction?
Q2) 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
Q3) List one reason when it is NOT acceptable to code a symptom code from Chapter 18.
Q4) In the inpatient setting,it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
A)True
B)False
Q5) What is the diagnosis code(s)for acute and chronic respiratory failure?
Q6) What is the diagnosis code(s)for acute and chronic renal failure?
Q7) If a patient is admitted for a complication due to a surgical procedure,the reason for the surgical procedure is the principal diagnosis.
A)True
B)False
Q8) What is the diagnosis code(s)for acute and chronic bronchitis?
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Chapter 6: Introduction to ICD-10-PCS
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Sample Questions
Q1) EGD with biopsy of the lower esophagus
Q2) Alphabetic Index entry for gastric banding (stomach)
Q3) If the identical procedure is performed on contralateral body parts and a bilateral body part value is available for that body part,two codes with the right and left body part should be assigned.
A)True
B)False
Q4) ____________________ is an adjunct procedure that allows increased visualization and more precise navigation during surgery.
Q5) Moving all or a portion of a body part to its normal location or other suitable location is called ____.
A)reposition
B)release
C)transfer
D)transplantation
Q6) Sutures are considered a device.
A)True
B)False
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) Mechanical respiratory ventilation less than 24 hours
Q2) Hearing treatment with cerumen management
Q3) In the extracorporeal assistance and performance section,the definition for assistance is completely taking over a physiological function by extracorporeal means.
A)True
B)False
Q4) In the substance abuse section,characters five,six,and seven are for qualifiers.
A)True
B)False
Q5) Chiropractic treatment to cervical spine using short lever specific contact
Q6) Nonautologous bone marrow transplant via central venous catheter
Q7) The term products of conception refers only to the fetus.
A)True
B)False
Q8) When a code from Section X is assigned,an adjunctive code from another table also needs to be assigned.
A)True
B)False
Q9) ECMO,circulatory,continuous Page 9
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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Sample Questions
Q1) Percutaneous aspiration of left perirenal abscess
Q2) Open annuloplasty of the mitral valve with Carpentier-Edwards ring
Q3) Open thyroidectomy with removal of the entire right lobe
Q4) An obstetric procedure is any procedure performed on a pregnant woman.
A)True
B)False
Q5) 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 ____.
Q6) Lysis of small intestinal adhesions,open approach
Q7) Laparoscopic-assisted vaginal hysterectomy
Q8) Root operation to remove some/all of a body part
A)Drainage
B)Excision
C)Occlusion
D)Release
E)Removal
F)Reposition
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Q9) Heart transplant,cadaver donor with extracorporeal circulation auxiliary during the open heart surgery
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 was admitted for prophylactic breast removal.The patient has a strong family history of breast cancer and the patient has severe fibrocystic disease in both breasts,making breast examination difficult.The patient was taken to the OR,and a bilateral simple mastectomy was performed.The patient recovered with no problems.The pathology report showed no evidence of malignancy.
Final Diagnosis: Family history of breast cancer;severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
A)Z40.8,N60.11,N60.12,0HTV0ZZ
B)Z40.01,Z80.3,N60.11,N60.12,0HTV0ZZ
C)Z40.01,Z80.3,N60.19,0HTT0ZZ,0HTU0ZZ
D)N60.11,N60.12,Z40.01,0HTT0ZZ,0HTU0ZZ
Q2) Urinary hesitancy due to enlarged prostate: __________
Q3) A ________________ is subjective evidence of a disease or of a patient's condition as perceived by the patient.
Q4) Positive Mantoux test: __________
Q5) Camp physical: __________
Q6) Screening for sickle cell disorder: __________
Q7) Gas pain: __________
Q8) Screening for osteoporosis: __________ Page 12
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Chapter 10: Certain Infectious and Parasitic Diseases
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Sample Questions
Q1) What disease is caused by a fungus?
A)Syphilis
B)HIV
C)Gonorrhea
D)Candidiasis
Q2) What disease causes inflammation of the liver and can be caused by several different viruses?
Q3) The systemic inflammatory response to infection or trauma;includes fevers,tachycardia,and leukocytosis
A)SIRS
B)Bacteremia
C)Septicemia
D)Gonorrhea
E)Septic shock
F)Sepsis
Q4) Infectious diseases are characterized often by a disease code and an organism code.When this occurs,it is appropriate to use two codes.
A)True
B)False
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Chapter 11: Neoplasms
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Sample Questions
Q1) A patient is being treated for chemotherapy-induced anemia.Patient is receiving chemotherapy for right renal cell carcinoma.
A)C64.9,D63.0,T45.1X1A
B)D64.89,T45.1X1A,C64.2
C)C64.1,D64.81,T45.1X5A
D)D64.81,T45.1X5A,C64.1
Q2) Malignant growth of connective tissue
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
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Page 15
Chapter 12: Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving the Immune
Mechanism
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Sample Questions
Q1) Childhood anemia: __________
Q2) What is the function of leukocytes (WBCs)?
Q3) Coagulopathy due to chronic liver disease: __________
Q4) ____ drugs are used to prevent the clumping of platelets or the formation of arterial thrombi.
A)Antiplatelet
B)Neutropenia
C)Apheresis
D)Anticoagulant
Q5) ____________________ is an increased number of white cells in the blood.
Q6) A patient takes Coumadin for chronic atrial fibrillation.
A)I48.1,Z79.01
B)I48.2,Z79.01
C)Z79.01
D)I48.0,Z79.02
Q7) End-stage renal disease with erythropoietin-resistant anemia: __________
Q8) Radiation therapy,drugs that are used for chemotherapy,and other chemicals may Page 16
result in neutropenia.
A)True
B)False
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Page 17
Chapter 13: Endocrine, nutritional, and Metabolic Diseases
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Sample Questions
Q1) The correct abbreviation for diabetes mellitus is ____________________.
Q2) Myxedema is a skin or tissue disorder usually resulting from severe,prolonged hypothyroidism.
A)True
B)False
Q3) Hypothyroidism in patient who has had a previous thyroidectomy: __________
Q4) Lactic acidosis: __________
Q5) Hormone replacement therapy
A)Z79.890
B)Z90.411
C)Z83.49
D)Z86.39
E)Z71.3
Q6) A(n)____________________ is an enlargement of the thyroid gland.
Q7) Iritis right eye due to diabetes,type 2,out of control: __________
Q8) Diabetes mellitus with hypoglycemic coma: __________
Q9) The coding of diabetes mellitus can be complicated because of various manifestations that can be associated with the disease.
A)True
B)False Page 18
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Page 19
Chapter 14: Mental, behavioral, and Neuro developmental Disorders
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Sample Questions
Q1) Catatonic schizophrenia in remission: __________
Q2) 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
Q3) ____________________ is the active management of withdrawal symptoms in a patient who is physically dependent on alcohol or drugs.
Q4) Dementia with wandering: __________
Q5) Panic agoraphobia: __________
Q6) Cirrhosis of liver due to alcohol dependence in remission: __________
Q7) AIDS-related dementia: __________
20
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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) Legal blindness in the United States is defined as severe or profound impairment in both eyes.
A)True
B)False
Q2) Infection of the mastoid bone of the skull
A)Glaucoma
B)Hydrocephalus
C)Meningitis
D)Epilepsy
E)Parkinson's disease
F)Cataract
G)Cholesteatoma
H)Mastoiditis
I)Myasthenia gravis
J)Alzheimer's disease
Q3) What are the two main divisions of the nervous system?
Q4) Bilateral retrolental fibroplasia: __________
Q5) How is hydrocephalus treated most commonly?
Q6) Arcus senilis of the left eye: __________ Page 21
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Chapter 16: Diseases of the Circulatory System
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Sample Questions
Q1) A patient is admitted with dyspnea and fluid overload.Chest X-ray reveals bilateral pleural effusion,right greater than left,and pulmonary congestion with possible congestive heart failure.BNP is elevated,confirming congestive heart failure.Echo shows a mild pulmonary hypertension and aortic valve stenosis.The patient is receiving medication for atrial fibrillation and has a history of alcoholic cardiomyopathy and alcohol dependence.
Discharge Diagnoses:
Congestive heart failure.
Pulmonary hypertension.
Aortic valve stenosis.
Atrial fibrillation.
Q2) Bifascicular block: __________
Q3) Diuretics such as Lasix,Bumex,and Zaroxolyn;beta blockers
A)Angina
B)Atrial fibrillation
C)Congestive heart failure
D)Hypertension
Q4) Sick sinus syndrome: __________
Q5) What is the function of blood vessels?
Q6) Prinzmetal angina: __________
Page 23
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Chapter 17: Diseases of the Respiratory System
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Sample Questions
Q1) In relation to the respiratory system,what does RUL stand for?
A)Right upper lip
B)Reasonable upper length
C)Right upper lobe
D)Right upper lid
Q2) In ICD-10-CM,if a respiratory condition occurs in more than one site and is not specifically indexed,each site should be coded separately.
A)True
B)False
Q3) A 1-year-old male was admitted with barking cough,stridor,and hoarseness.The patient was up-to-date on all vaccinations and had achieved normal developmental milestones.Patient was treated for acute laryngotracheobronchitis and recovered.
Discharge Diagnosis: Acute laryngotracheobronchitis.
A)J20.9,R06.1
B)R06.1,J40
C)J41
D)J20.9
Q4) The condition where fluid accumulates in the lungs is called
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Chapter 18: Diseases of the Digestive System
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Sample Questions
Q1) Retrocecal abscess: __________
Q2) Procedure performed to remove adhesions from the body
A)Nissen fundoplication
B)Herniorrhaphy
C)Appendectomy
D)Colostomy
E)Lysis of adhesions
F)PEG (percutaneous endoscopic gastrostomy)
G)TIPS (transjugular intrahepatic portosystemic shunt)procedure
H)Whipple procedure
Q3) A patient presents with melena,weakness,and fatigue.A colonoscopy with biopsy of the rectum and colon is performed and reveals multiple diverticula and internal hemorrhoids.No source of bleeding is identified.Discharge Diagnosis: GI bleed;chronic blood loss anemia.
A)D50.0,K92.2,K57.91,K64.8,0DBE8ZX
B)K92.1,D50.0,K57.30,K64.8,0DBE8ZX,0DBP8ZX
C)K92.2,D62,K57.30,K64.9,0DBE8ZX,0DBP8ZX
D)K57.91,K92.1,D50.0,K64.9,0DBE8ZX,0DBP8ZX
Q4) What is an ulcer (such as of the stomach or intestine)?
Q5) Appendicitis with abscess: __________
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Chapter 19: Diseases of the Skin and Subcutaneous Tissue
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Sample Questions
Q1) When dermatitis is caused by contact with a substance,it is called ____ dermatitis.
A)exogenous
B)endogenous
C)mesogenous
D)outer contact
Q2) Patient has a pressure ulcer of the left ankle on admission,which is documented as a stage 1 and progresses to a stage 3 during the course of the stay.The patient is a paraplegic.
A)L97.309,G82.22
B)L89.523,G82.20
C)L97.319,G82.20
D)L89.511,L89.523,G82.22
Q3) 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
Q4) The sebaceous glands secrete an oily substance called
Q5) What are the three types of glands located in the skin?
Page 26
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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Sample Questions
Q1) What is the purpose of the musculoskeletal system?
Q2) The front of the body or organ
A)Medial
B)Cranial
C)Ventral
D)Superior
E)Caudal
F)Dorsal
G)Lateral
Q3) ____________________ is a metabolic bone disorder that results in decreased bone mass and density.
Q4) Alendronate,calcitonin,and calcium with vitamin D are common medications used to treat osteoporosis.
A)True
B)False
Q5) Myelopathy is compression of the ____________________.
Q6) Spinal stenosis is the widening or rupture of the spinal canal. A)True B)False
Q7) Degenerative polyarticular arthritis: __________ Page 27
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) Overflow incontinence is the constant dribbling of urine.Treatments for overflow incontinence include all of the following EXCEPT ____.
A)Kegel exercises
B)diet
C)immediate surgery
D)bladder training
Q2) UTI stands for ____________________.
Q3) Sudden and severe impairment of renal function characterized by oliguria,increased serum urea,and acidosis
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
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Chapter 22: Pregnancy, childbirth, and the Puerperium
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Sample Questions
Q1) Lupus nephritis in second trimester of pregnancy (20 weeks): __________
Q2) Severe antepartum deep thrombophlebitis of the right calf at 25 weeks:
Q3) The organs of the female reproductive system include the ovaries,fallopian tubes,uterus,vagina,and cervix.
A)True
B)False
Q4) A 40-week primigravida patient comes to the hospital in labor.Labor progresses,and she delivers a normal 7.6-pound infant.An episiotomy is performed and repaired.The patient had a UTI during the fourth month of pregnancy that was treated with antibiotics.She suffered from hyperemesis gravidarum early in the pregnancy.She is discharged on day 2 with no complaints.What codes are applicable? __________
Q5) A type of abortion with fetal demise before 20 weeks but no products of conception are expelled is a(n)______________ abortion.
Q6) A woman pregnant at 43 weeks is still considered to be a term pregnancy.
A)True
B)False
Q7) In referring to a pregnant woman,what does antepartum mean?
Q8) What does it mean when a pregnant woman is called primigravida?
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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) Cleft lip occurs in approximately 1 in every 2000 babies.
A)True
B)False
Q2) What is a congenital anomaly?
Q3) Newborn is delivered vaginally and is ruled in for group B strep sepsis.
A)Z38.00,A41.9,R65.20,P00.2
B)Z38.01,P00.2
C)Z38.01,R65.20,A41.9
D)Z38.00,P36.0
Q4) Cesarean delivery at term of baby;hypothermia (not environmental)noted on admit to nursery: __________
Q5) An infant is born via vaginal delivery with intrauterine growth retardation.The baby is premature being born at 33 2/7 weeks and weighing 1800 grams.Meconium aspiration is noted at delivery.Jaundice due to prematurity,which was treated with phototherapy (non-ultraviolet),single session.
A)Z38.00,P05.9,P24.01,P59.0,6A600ZZ
Page 31
B)Z38.00,P07.17,P07.36,P24.00,P59.0,6A600ZZ
C)Z37.0,P05.9,P07.35,P24.00,P59.0,6A600ZZ
D)Z37.0,P07.36,P24.00,P59.0,6A600ZZ
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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) When air or gas bubbles get into the bloodstream,what is one thing that can happen?
Q2) Open dislocation (open wound),right acromioclavicular joint,initial encounter:
Q3) What does TBI stand for?
Q4) Organ or tissue replaced by transplant-bone
A)Z94.6
B)Z89.211
C)Z89.432
D)Z87.820
E)Z91.81
Q5) A 7-year-old child is admitted to the hospital with fractured shaft of right humerus after falling out of a tree.The patient is taken to the OR for ORIF.__________
Q6) When the primary injury is to the blood vessels or nerves,that injury should be sequenced first.
A)True
B)False
Q7) Fractured coccyx,initial encounter: __________
Q8) Open-fracture fifth metatarsal on the right,initial encounter: __________ Page 33
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) External cause code(s)are never used to identify the cause and intent of the injury or poisoning.
A)True
B)False
Q2) When the reason for the admission or encounter is to provide treatment for external multiple burns,sequence first the code that reflects the burn of the highest degree.
A)True
B)False
Q3) Sunburned chest: __________
Q4) Active treatment of nonhealing second-degree burn to right forearm due to hot iron while ironing (accidental): __________
Q5) Debridements must always be done in the OR.
A)True
B)False
Q6) Full-thickness skin loss
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
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Chapter 26: Complications of Surgical and Medical Care
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Q1) Rejection of heart transplant confirmed by right percutaneous ventricular biopsy:
Q2) What are some examples of procedures resulting in complications that occur during medical care and not during surgery?
Q3) Pneumonitis due to organism growing in ventilation (air conditioning)system:
Q4) Patient with acute osteomyelitis right femur due to infected right knee joint replacement,initial encounter: __________
Q5) The decay of tissue
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q6) When looking for a complication code in the Index,the coder should first look under the ____________________.
Q7) Mechanical complication of gastrostomy: __________
Q8) What does DVT stand for?
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