HIM CODING THEORY TEST

Question 1 of 81

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A Diagnosis Type 6 is assigned to:

Select one of the following:

  • MP that requires treatment beyond maintenance of the preexisting condition; Increases the length of stay (LOS) by at least 24 hours

  • a designated asterisk code in a dagger asterisk convention when the condition it represents fulfills the requirements stated in the definition for Type M - Most Responsible Diagnosis

  • codes for symptoms or signs which are characteristic of the diagnosis

  • code conditions described as "ruled out."

Question 2 of 81

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A set of standardized terms and their synonyms that record patient findings, circumstances, events and interventions

Select one of the following:

  • Interface terminology

  • Classification

  • Nomenclature

  • Clinical reference terminologies

Question 3 of 81

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SNOMED CT concepts are organized into ____ hierarchies.

Select one of the following:

  • 19

  • 21

  • 15

  • 5

Question 4 of 81

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Which is not apart of the SNOMED CT hierarchies

Select one of the following:

  • Diseases and interventions

  • Diagnoses and symptoms

  • Devices and findings

  • Medications and Laboratory testings

Question 5 of 81

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Hierarchies have multiple____which allows information to be expressed with different levels of detail and precision which means data can be entered or retrieved depending on the need.

Select one of the following:

  • Granularities

  • Classifications

  • Cathegories

  • terminologies

Question 6 of 81

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RAI is described as an assessment tool to document characteristics of residents

Select one of the following:

  • True
  • False

Question 7 of 81

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A Type 2 Diagnosis Type describes a condition that arises post-admission and satisfies the requirements for determining comorbidity and applies to both DAD and NACRS?

Select one of the following:

  • True
  • False

Question 8 of 81

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A ______________ is a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.

Select one of the following:

  • Nomenclature

  • Classification

  • Code Assignment

  • Interpretation

Question 9 of 81

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Is a classification that allows for the categorizing of patient reason for encounter designed to be used in a primary care setting

Select one of the following:

  • LOINC

  • ICD-O

  • ICPC

  • ICNP

Question 10 of 81

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Is a multi-axial classification of categories used to collect psychiatric disorders and underlying conditions

Select one of the following:

  • ICD 10 CA

  • DSM-IV

  • CPT

  • CIHI

Question 11 of 81

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Includes gender, data of birth, and postal codes

Select one of the following:

  • Clinical Data

  • Administrative Data

  • Statistical Data

  • Demographic Data

Question 12 of 81

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inpatient records, ER records, and ambulatory records are examples of Source Documents

Select one of the following:

  • True
  • False

Question 13 of 81

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Includes those interventions that are through a needle or catheter

Select one of the following:

  • ENDOSCOPIC PER ORIFICE Approach

  • PERCUTANEOUS Approach

  • OPEN Approach

  • EXTERNAL Approach

Question 14 of 81

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Describes a situation in which the intervention is terminated before an expected outcome is achieved

Select one of the following:

  • Revised Interventions

  • Failed Intervention

  • Abandoned Interventions

  • Suspended Interventions

Question 15 of 81

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Interventions from this section are solely used for obstetrics and neonates

Select one of the following:

  • Section 2

  • Section 3

  • Section 5

  • Section 3 and 5

Question 16 of 81

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Qualifiers (Field 4, 5, 6) describe the devices being used and related tissue and grafts.

Select one of the following:

  • True
  • False

Question 17 of 81

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This contains two characters and refers to "what is being done"

Select one of the following:

  • Field 3

  • Field 1

  • Field 2

  • Field 4

Question 18 of 81

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This coded to reflect the existence of a separate surgical wound which usually requires its own post-surgical care (example would be a free flap)

Select one of the following:

  • Status Attribute

  • Procurement

  • Location Attribute

  • Free Flap

Question 19 of 81

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These are used to indicate quantitative measures related to the intervention

Select one of the following:

  • Extent Attribute

  • Location Attribute

  • Field Attribute

  • Status Attribute

Question 20 of 81

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Select all the correct Interventions to Manage Bleeding

Select one or more of the following:

  • 1...13

  • 1..51

  • 1....31

  • 1...59

Question 21 of 81

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Composite of Codes in CCI describes a situation when one CCI code is not enough to describe the complex invention and requires an additional CCI code

Select one of the following:

  • True
  • False

Question 22 of 81

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This instruction is provided to also code associated factors in a condition such as infecting organism, underlying causes, asterisk code, to further describe a person's condition

Select one of the following:

  • Dual Classification

  • Use Additional Code

  • Combination Codes

  • Classification systems

Question 23 of 81

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This consists of numeric listing in code number order and is organized by chapter, blocks, and categories

Select one of the following:

  • Tabular Listing

  • Alphabetical Index

  • Classification system

  • Secondary Terms

Question 24 of 81

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NOS is given to code (s) to represent a condition or disease that has not been otherwise specialized

Select one of the following:

  • True
  • False

Question 25 of 81

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Dual Classification is a single code that classifies two conditions or a diagnosis with an associated secondary process (manifestation) or complication; a relationship exists between the two conditions

Select one of the following:

  • True
  • False

Question 26 of 81

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Secondary Term is located in the alphabetical index binocular, referring to the "modifiers" or anatomical site, the type of disease, injury or etiology

Select one of the following:

  • True
  • False

Question 27 of 81

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This represents a level of grouping between chapters and categories, an example would be: N60-N64

Select one of the following:

  • Blocks

  • Cathegories

  • Stages

  • Residual Categories

Question 28 of 81

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This can be at the fourth or fifth character of code and is used for "other" conditions (not specified)

Select one of the following:

  • ".9"

  • ".8"

  • ".5"

  • 00

Question 29 of 81

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Lead Term is located in the _____________________ binocular, using the name of the disease, injury or pathological condition

Select one of the following:

  • Tabular

  • Alphabetical index

  • Table of Drugs

  • Neoplasm

Question 30 of 81

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These conditions provide further information about conditions which are no longer present but are the cause of the current problem, often listed as "old, late effect, or due to previous"

Select one of the following:

  • Post Condition

  • Sequelae Condition

  • Prefix "Q"

  • Not elsewhere Classified

Question 31 of 81

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Uses the code Z21 when there is no documentation of an indicator disease from the National Surveillance case definition list.

Select one of the following:

  • HIV Positive

  • MRSA

  • HIV Carrier

  • HIV Exposed

Question 32 of 81

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This is known as a drug resistant bacteria

Select one of the following:

  • UTI

  • Kaposi's sarcoma

  • MRSA

  • Y83

Question 33 of 81

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This can only be coded when documented by a physician and not on the basis of laboratory values alone

Select one of the following:

  • Tuberculosis

  • Septicemia

  • Carrier

  • Contagious infection

Question 34 of 81

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Must be used as a type 3 to identify patients who have been exposed to or had contact with AIDS/HIV

Select one of the following:

  • B24

  • Y83

  • Z20.6

  • Z21

Question 35 of 81

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This term describes when the microbiology report may indicate the patient has MRSA, VRE on their body but the patient is not sick with the illness, these are coded to "carriers

Select one of the following:

  • Colonization

  • Diagnoses cluster

  • PUO

  • Wasting Syndrome

Question 36 of 81

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Is used by physicians to describe a patient who presents with a fever, and the cause is not determined after investigations are completed

Select one of the following:

  • PUO

  • U82 - U85

  • SIRS

  • R65.1

Question 37 of 81

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This code must be assigned as a diagnosis type 1 or type 2 to describe organ failure as a result of severe sepsis

Select one of the following:

  • R65.1

  • O98.7

  • Y79

  • Z21

Question 38 of 81

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This describes when the healing process of a bone has not occurred and there is still separation of the bony structures involved in the fracture

Select one of the following:

  • Non-mechanical complications

  • Non-union

  • Mechanical Complications

  • Dual component

Question 39 of 81

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This is often referred to as a THR where the femoral head and neck are replaced

Select one of the following:

  • Dual component

  • Displacement

  • R65.1

  • Closed fracture

Question 40 of 81

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This term is often referred to as herniation and/or protrusion of the intervertebral disc, and the condition may also be described as prolapsed disc or sequestrated disc.

Select one of the following:

  • Closed fracture

  • Seborrheic Keratosis

  • Non-union

  • Displacement

Question 41 of 81

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This code is assigned as a MP when a patient returns to day surgery after the fracture has healed for removal of an internal fixation device such as a wire, pins or plate.

Select one of the following:

  • Z47.8

  • Z47.0

  • Y83.1

  • Y79

Question 42 of 81

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This describes a procedure which uses organ or tissue from an animal source

Select one of the following:

  • Z plasty

  • Autograft

  • Xenograft

  • Homograft

Question 43 of 81

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1.YM.79^^ CCI code is assigned together with the diagnosis code of Z41.1 when the patient is has no abnormality of their breast but is dissatisfied with their breast size

Select one of the following:

  • True
  • False

Question 44 of 81

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Pedicle flap uses a special balloon which is placed under the skin next to the area where the new tissue is needed to grow new skin for reconstruction

Select one of the following:

  • True
  • False

Question 45 of 81

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Pilonidal disease occurs in the sacrococcygeal region and can present as an abscess, a draining sinus or a fluctuating mass

Select one of the following:

  • True
  • False

Question 46 of 81

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This condition can result from an adverse effect of medication taken internally as directed and is assigned the code L27^

Select one of the following:

  • Cellulitis

  • Decubitus ulcer

  • Free flap

  • Dermatitis

Question 47 of 81

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This condition can be described as either spontaneous or compression when involving the vertebrae, it occurs in bones weakened by pre-existing disease such as osteoporosis, Paget's disease and neoplasia

Select one of the following:

  • Pathological Fracture

  • Pilonidal disease

  • Nonunion Fracture

  • Tissue Expansion

Question 48 of 81

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A patient arrived in hospital for an elective hip arthroplasty for osteoarthritis. Surgery was performed using a dual component THR without incident. On the third day the patient developed a wound infection resulting from the device inserted. Staphylococci were found on the cultures. The patient required to stay in hospital for another 3 days until the infection has cleared. What would be the MRDX?

Select one of the following:

  • The post-admit comorbidity diagnosis would be: non-mechanical complication of a joint prosthesis

  • Hip Arthroplasty for Osteoarthritis

  • The pre-admit comorbidity diagnosis would be: mechanical complication of a joint prosthesis

  • Hip arthroplastyusing dual component THR

Question 49 of 81

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A 17 year old male patient arrived in the emergency room with pain in his knee after falling down a hill yesterday while skiing at Blue Mountain. The patient had an x-ray of the knee indicated there was a ligament injury of the right knee. The patient was transferred to an inpatient bed and kept overnight awaiting surgery in the morning. What would be the main problem for the emergency visit?

Select one of the following:

  • Pain in the knee ligament

  • current injury of the knee ligament

  • X-ray of the knee ligament

  • old injury of the knee ligament

Question 50 of 81

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A female patient has developed cellulitis on her hand from an infected open wound which was caused by a cut from a garbage can. She is being treated with IV antibiotics for three days, and was discharged home. Which of the following would be the most responsible diagnosis?

Select one of the following:

  • cut from a garbage can

  • IV antibiotics treatment

  • cellulitis on the hand

  • open wound on the hand

Question 51 of 81

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An 77 year old male patient is admitted to treat degenerative arthritis of the right hip. On the history note it states the patient has diabetes type 2, hypertension and congestive heart failure. The patient was taken to the OR room where a THR was performed with excellent results. What would be the most responsible diagnosis?

Select one of the following:

  • Primary arthrosis

  • Secondary arthrosis

  • Degenerative arthrtis

  • Diabetes Type 2

Question 52 of 81

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A patient was admitted to hospital for a breast lumpectomy for infiltrating duct carcinoma. During the procedure the surgeon also removed all the axillary lymph nodes because of metastases. Post-op the patient had a chest tube inserted for pneumothorax. A CT scan of the chest performed before the patient was discharged indicated the pneumothorax had resided. What procedure would be sequenced first, also known as the principle procedure?

Select one of the following:

  • Chest tube for pneumothorax

  • CT Scan of the chest

  • Breast lumpectomy

  • Endoscopic per orifice pneumothorax

Question 53 of 81

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It is mandatory to assign the code Z51.1 and a CCI code for the administration of the pharmaceutical agent, plus a code from C00-C97 when a patient arrives in a hospital for the admission of:

Select one of the following:

  • Radiology

  • Chemotherapy

  • Remission

  • Follow-up examination

Question 54 of 81

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This is a complication/side effect of cancer treatment, and can be a type 2 if it occurred during a patient's admission for initial treatment for cancer/or satisfies the criteria for a post-admit comorbidity

Select one of the following:

  • Neutropenia

  • Wasting Syndrome

  • Palliative care

  • Hypoxia

Question 55 of 81

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This is used as 5th digit for malignant secondary neoplasm

Select one of the following:

  • /3

  • /1

  • /6

  • /0

Question 56 of 81

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Bone rule state morphology to be intraosseous or odontogenic to be classified as a primary neoplasm

Select one of the following:

  • True
  • False

Question 57 of 81

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This information is necessary to capture if patients are requesting prophylactic surgery and is assigned the code Z80.-

Select one of the following:

  • Reccurent malignancy

  • Family hx of malignancy

  • Personal hx of malignancy

  • Metastases to

Question 58 of 81

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This term is used when the patient is described as having cancer that has spread to multiple secondary sites

Select one of the following:

  • Carcinomatosis

  • Connective tissue tumors

  • Bone Tumor

  • Papilloma

Question 59 of 81

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When a patient is admitted for this type of treatment, a code for the malignant disease is assigned as the MRDX/MP

Select one of the following:

  • Chemotherapy

  • Radiology

  • Brachytherapy

  • Immunotherapy

Question 60 of 81

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C80.0 code is used when certain tests such as CA 125 or PSA may be elevated but after investigation and/or observation shown the condition of cancer has been ruled out, so there is no condition to code.

Select one of the following:

  • True
  • False

Question 61 of 81

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An example of an intervention performed by an endoscopic approach would be:

Select one of the following:

  • Tracheostomy

  • Thoracoscopy

  • Cholecystostomy

  • colonoscopy

Question 62 of 81

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A classification of categories used to collect psychiatric disorders and underlying conditions.

Select one of the following:

  • DSM-IV

  • ICD-O

  • SNOMED

  • ICD-10

Question 63 of 81

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Select all that are found in section 2 of the CCI

Select one or more of the following:

  • Right lobectomy

  • Arthroscopy

  • Laparoscopy

  • Biopsy

Question 64 of 81

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What section of CCI would include MRI's, CT Scans and X-Rays?

Select one or more of the following:

  • Section 3

  • Section 1

  • Section 5

  • Section 2

Question 65 of 81

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There are ________ chapters in ICD 10 CA and __________ chapters in CCI.

Select one or more of the following:

  • 19 chapters for CCI

  • 23 chapters for ICD 10

  • 19 chapters for ICD 10

  • 23 chapters for CCI

Question 66 of 81

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A doctor has documented on the face sheet of an emergency record a condition of a fracture of the right femur due to a fall from a ladder. After examination of the record the x-ray results indicate a fracture of the proximal end of the femur. What should be coded as the MP based on the rule for specificity?

Select one of the following:

  • Fracture right femur

  • fracture of the proximal end of the femur

  • Fall from ladder

Question 67 of 81

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When coding sequelae of injuries the following rule applies:

Select one of the following:

  • Code the sequelae diagnosis as a diagnosis type 3 and the condition being treated as Type 1

  • Code the sequelae diagnosis as a diagnosis type 1 and the condition being treated as MRDX/MP

  • Only code the sequelae diagnosis

  • Code the sequelae diagnosis as a diagnosis OP and the condition being treated as Type 1

Question 68 of 81

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A 54 year old patient arrives in the emergency department complaining of coughing up blood. The emergency physician ordered a chest x-ray and a TB test. Results are pending at this time. An appointment was made for the patient to see a respirologist for the results of the test. The final diagnosis documented by the physician is hemoptysis and questionable TB of the lung. What would be could as the main problem?

Select one of the following:

  • Hemoptysis

  • Query Tuberculosis of the lung

  • Tuberculosis of the lung

  • Chest X-ray

Question 69 of 81

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A 38 year old female arrived in the emergency department with a laceration on her hand after falling from her patio. She has a past medical history of type 2 diabetes. The emergency physician sutured and dressing her wound under local anesthesia. The patient indicated she was feeling faint and a blood glucose tolerance test was performed indicating levels were higher than normal. The emergency physcian ordered her to be admitted to an inpatient bed for observation overnight to control her condition of diabetes. What would be the principal procedure for the ER visit?

Select one of the following:

  • local anesthesia

  • blood glucose tolerance test

  • laceration on her hand

  • Suture of the laceration of the hand

Question 70 of 81

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A patient was admitted to hospital from the ER with a diagnosis of severe cough and the condition of impeding pneumonia. On the x-ray report done in the ER indicated the patient has severe bronchitis. The patient was given large doses of antibiotics. After 4 days in hospital the pneumonia was ruled out and the patient was discharged. The physician documents on the face sheet acute bronchitis. What code should the coder assign and the MRDX?

Select one of the following:

  • impeding pneumonia

  • severe bronchiti

  • acute bronchitis

  • severe cough

Question 71 of 81

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The following are correct when referring to a comorbidity

Select one or more of the following:

  • Are conditions that coexists at the time of admission and significantly affect the treatment received.

  • Require a consultation to assess a previously undiagnosed condition

  • Are conditions that increase the LOS by at least 24 hours.

  • Require a consultation to assess a previous undiagnosed condition

Question 72 of 81

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Is the building blocks of information, the raw facts and figures ( the elements, S01.90, V43.5, 1.YB.80.LA, 1811, F, age 47, outcome of visit - discharged home (D) or died (E)) - facts on their own have no meaning

Select one of the following:

  • Information

  • Knowledge

  • Wisdom

  • Data

Question 73 of 81

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Encoded data refers to transferring data into computer language, which can be stored into computer programs that can be transformed into meaningful health care information

Select one of the following:

  • True
  • False

Question 74 of 81

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Which of the following does not affect Data Quality?

Select one of the following:

  • interpreted

  • entered

  • stored

  • aggerated

Question 75 of 81

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International Health Terminology Standards Development Organization (IHTSDO) is a not-for-profit association that develops and
promotes use of SNOMED CT to support safe and effective health information exchange.

Select one of the following:

  • True
  • False

Question 76 of 81

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Which of the following is NOT an axis of Systematized Nomenclature of Pathology (SNOP)?

Select one of the following:

  • Morphology (pathologic anatomy...disease process)

  • Etiology (agents causing disease)

  • Function (functional disorders in the patho-physiological sense)

  • Interventions

Question 77 of 81

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SNOMED CT concepts are organized into 19 hierarchies that includes

Select one or more of the following:

  • disease, interventions

  • symptoms, diagnoses

  • morphology, etiology

  • medications, findings

Question 78 of 81

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Semantic interoperability is the ability of computer systems to communicate (two systems will derive the same inferences from the same information)...basically to share
unambiguous meaning

Select one of the following:

  • True
  • False

Question 79 of 81

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Data Quality is required to be maintained by going through the data periodically (select the following which applies).

Select one or more of the following:

  • scrubbing it

  • destroying it

  • standardizing it

  • updating it

Question 80 of 81

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Understanding the fundamental principles embodied within the knowledge, utilizing knowledge to make sense and have an insight of what is happening

Select one of the following:

  • Wisdom

  • Knowledge

  • Data

  • Information

Question 81 of 81

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A right breast neoplasm in the anatomical site of 5:00 would be given the code of _________

Select one of the following:

  • C50.30

  • C50.80

  • C50.51

  • C50.31

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HIM CODING THEORY TEST

Dwayne Campbell
Quiz by , created about 2 years ago

Quiz on HIM CODING THEORY TEST, created by Dwayne Campbell on 20/10/2014.

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