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HIM CODING THEORY TEST
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Questions in this quiz (81)
1A Diagnosis Type 6 is assigned to:
- AMP that requires treatment beyond maintenance of the preexisting condition; Increases the length of stay (LOS) by at least 24 hours
- Ba 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
- Ccodes for symptoms or signs which are characteristic of the diagnosis
- Dcode conditions described as "ruled out."
- AMP that requires treatment beyond maintenance of the preexisting condition; Increases the length of stay (LOS) by at least 24 hours
2A set of standardized terms and their synonyms that record patient findings, circumstances, events and interventions
- AInterface terminology
- BClassification
- CNomenclature
- DClinical reference terminologies
3SNOMED CT concepts are organized into ____ hierarchies.
- A19
- B21
- C15
- D5
4Which is not apart of the SNOMED CT hierarchies
- ADiseases and interventions
- BDiagnoses and symptoms
- CDevices and findings
- DMedications and Laboratory testings
- ADiseases and interventions
5Hierarchies 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.
- AGranularities
- BClassifications
- CCathegories
- Dterminologies
6RAI is described as an assessment tool to document characteristics of residents
- ATrue
- BFalse
7A 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?
- ATrue
- BFalse
8A ______________ is a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.
- ANomenclature
- BClassification
- CCode Assignment
- DInterpretation
9Is a classification that allows for the categorizing of patient reason for encounter designed to be used in a primary care setting
- ALOINC
- BICD-O
- CICPC
- DICNP
10Is a multi-axial classification of categories used to collect psychiatric disorders and underlying conditions
- AICD 10 CA
- BDSM-IV
- CCPT
- DCIHI
11Includes gender, data of birth, and postal codes
- AClinical Data
- BAdministrative Data
- CStatistical Data
- DDemographic Data
12inpatient records, ER records, and ambulatory records are examples of Source Documents
- ATrue
- BFalse
13Includes those interventions that are through a needle or catheter
- AENDOSCOPIC PER ORIFICE Approach
- BPERCUTANEOUS Approach
- COPEN Approach
- DEXTERNAL Approach
14Describes a situation in which the intervention is terminated before an expected outcome is achieved
- ARevised Interventions
- BFailed Intervention
- CAbandoned Interventions
- DSuspended Interventions
15Interventions from this section are solely used for obstetrics and neonates
- ASection 2
- BSection 3
- CSection 5
- DSection 3 and 5
16Qualifiers (Field 4, 5, 6) describe the devices being used and related tissue and grafts.
- ATrue
- BFalse
17This contains two characters and refers to "what is being done"
- AField 3
- BField 1
- CField 2
- DField 4
18This coded to reflect the existence of a separate surgical wound which usually requires its own post-surgical care (example would be a free flap)
- AStatus Attribute
- BProcurement
- CLocation Attribute
- DFree Flap
19These are used to indicate quantitative measures related to the intervention
- AExtent Attribute
- BLocation Attribute
- CField Attribute
- DStatus Attribute
20Select all the correct Interventions to Manage Bleeding
- A1...13
- B1..51
- C1....31
- D1...59
21Composite 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
- ATrue
- BFalse
22This 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
- ADual Classification
- BUse Additional Code
- CCombination Codes
- DClassification systems
23This consists of numeric listing in code number order and is organized by chapter, blocks, and categories
- ATabular Listing
- BAlphabetical Index
- CClassification system
- DSecondary Terms
24NOS is given to code (s) to represent a condition or disease that has not been otherwise specialized
- ATrue
- BFalse
25Dual 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
- ATrue
- BFalse
26Secondary Term is located in the alphabetical index binocular, referring to the "modifiers" or anatomical site, the type of disease, injury or etiology
- ATrue
- BFalse
27This represents a level of grouping between chapters and categories, an example would be: N60-N64
- ABlocks
- BCathegories
- CStages
- DResidual Categories
28This can be at the fourth or fifth character of code and is used for "other" conditions (not specified)
- A".9"
- B".8"
- C".5"
- D00
29Lead Term is located in the _____________________ binocular, using the name of the disease, injury or pathological condition
- ATabular
- BAlphabetical index
- CTable of Drugs
- DNeoplasm
30These 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"
- APost Condition
- BSequelae Condition
- CPrefix "Q"
- DNot elsewhere Classified
31Uses the code Z21 when there is no documentation of an indicator disease from the National Surveillance case definition list.
- AHIV Positive
- BMRSA
- CHIV Carrier
- DHIV Exposed
32This is known as a drug resistant bacteria
- AUTI
- BKaposi's sarcoma
- CMRSA
- DY83
33This can only be coded when documented by a physician and not on the basis of laboratory values alone
- ATuberculosis
- BSepticemia
- CCarrier
- DContagious infection
34Must be used as a type 3 to identify patients who have been exposed to or had contact with AIDS/HIV
- AB24
- BY83
- CZ20.6
- DZ21
35This 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
- AColonization
- BDiagnoses cluster
- CPUO
- DWasting Syndrome
36Is used by physicians to describe a patient who presents with a fever, and the cause is not determined after investigations are completed
- APUO
- BU82 - U85
- CSIRS
- DR65.1
37This code must be assigned as a diagnosis type 1 or type 2 to describe organ failure as a result of severe sepsis
- AR65.1
- BO98.7
- CY79
- DZ21
38This describes when the healing process of a bone has not occurred and there is still separation of the bony structures involved in the fracture
- ANon-mechanical complications
- BNon-union
- CMechanical Complications
- DDual component
39This is often referred to as a THR where the femoral head and neck are replaced
- ADual component
- BDisplacement
- CR65.1
- DClosed fracture
40This 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.
- AClosed fracture
- BSeborrheic Keratosis
- CNon-union
- DDisplacement
41This 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.
- AZ47.8
- BZ47.0
- CY83.1
- DY79
42This describes a procedure which uses organ or tissue from an animal source
- AZ plasty
- BAutograft
- CXenograft
- DHomograft
431.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
- ATrue
- BFalse
44Pedicle 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
- ATrue
- BFalse
45Pilonidal disease occurs in the sacrococcygeal region and can present as an abscess, a draining sinus or a fluctuating mass
- ATrue
- BFalse
46This condition can result from an adverse effect of medication taken internally as directed and is assigned the code L27^
- ACellulitis
- BDecubitus ulcer
- CFree flap
- DDermatitis
47This 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
- APathological Fracture
- BPilonidal disease
- CNonunion Fracture
- DTissue Expansion
48A 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?
- AThe post-admit comorbidity diagnosis would be: non-mechanical complication of a joint prosthesis
- BHip Arthroplasty for Osteoarthritis
- CThe pre-admit comorbidity diagnosis would be: mechanical complication of a joint prosthesis
- DHip arthroplastyusing dual component THR
49A 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?
- APain in the knee ligament
- Bcurrent injury of the knee ligament
- CX-ray of the knee ligament
- Dold injury of the knee ligament
50A 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?
- Acut from a garbage can
- BIV antibiotics treatment
- Ccellulitis on the hand
- Dopen wound on the hand
51An 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?
- APrimary arthrosis
- BSecondary arthrosis
- CDegenerative arthrtis
- DDiabetes Type 2
52A 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?
- AChest tube for pneumothorax
- BCT Scan of the chest
- CBreast lumpectomy
- DEndoscopic per orifice pneumothorax
53It 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:
- ARadiology
- BChemotherapy
- CRemission
- DFollow-up examination
54This 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
- ANeutropenia
- BWasting Syndrome
- CPalliative care
- DHypoxia
55This is used as 5th digit for malignant secondary neoplasm
- A/3
- B/1
- C/6
- D/0
56Bone rule state morphology to be intraosseous or odontogenic to be classified as a primary neoplasm
- ATrue
- BFalse
57This information is necessary to capture if patients are requesting prophylactic surgery and is assigned the code Z80.-
- AReccurent malignancy
- BFamily hx of malignancy
- CPersonal hx of malignancy
- DMetastases to
58This term is used when the patient is described as having cancer that has spread to multiple secondary sites
- ACarcinomatosis
- BConnective tissue tumors
- CBone Tumor
- DPapilloma
59When a patient is admitted for this type of treatment, a code for the malignant disease is assigned as the MRDX/MP
- AChemotherapy
- BRadiology
- CBrachytherapy
- DImmunotherapy
60C80.0 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.
- ATrue
- BFalse
61An example of an intervention performed by an endoscopic approach would be:
- ATracheostomy
- BThoracoscopy
- CCholecystostomy
- Dcolonoscopy
62A classification of categories used to collect psychiatric disorders and underlying conditions.
- ADSM-IV
- BICD-O
- CSNOMED
- DICD-10
63Select all that are found in section 2 of the CCI
- ARight lobectomy
- BArthroscopy
- CLaparoscopy
- DBiopsy
64What section of CCI would include MRI's, CT Scans and X-Rays?
- ASection 3
- BSection 1
- CSection 5
- DSection 2
65There are ________ chapters in ICD 10 CA and __________ chapters in CCI.
- A19 chapters for CCI
- B23 chapters for ICD 10
- C19 chapters for ICD 10
- D23 chapters for CCI
66A 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?
- AFracture right femur
- Bfracture of the proximal end of the femur
- CFall from ladder
67When coding sequelae of injuries the following rule applies:
- ACode the sequelae diagnosis as a diagnosis type 3 and the condition being treated as Type 1
- BCode the sequelae diagnosis as a diagnosis type 1 and the condition being treated as MRDX/MP
- COnly code the sequelae diagnosis
- DCode the sequelae diagnosis as a diagnosis OP and the condition being treated as Type 1
68A 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?
- AHemoptysis
- BQuery Tuberculosis of the lung
- CTuberculosis of the lung
- DChest X-ray
69A 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?
- Alocal anesthesia
- Bblood glucose tolerance test
- Claceration on her hand
- DSuture of the laceration of the hand
70A 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?
- Aimpeding pneumonia
- Bsevere bronchiti
- Cacute bronchitis
- Dsevere cough
71The following are correct when referring to a comorbidity
- AAre conditions that coexists at the time of admission and significantly affect the treatment received.
- BRequire a consultation to assess a previously undiagnosed condition
- CAre conditions that increase the LOS by at least 24 hours.
- DRequire a consultation to assess a previous undiagnosed condition
- AAre conditions that coexists at the time of admission and significantly affect the treatment received.
72Is 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
- AInformation
- BKnowledge
- CWisdom
- DData
73Encoded data refers to transferring data into computer language, which can be stored into computer programs that can be transformed into meaningful health care information
- ATrue
- BFalse
74Which of the following does not affect Data Quality?
- Ainterpreted
- Bentered
- Cstored
- Daggerated
75International 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.- ATrue
- BFalse
76Which of the following is NOT an axis of Systematized Nomenclature of Pathology (SNOP)?
- A
Morphology (pathologic anatomy...disease process) - BEtiology (agents causing disease)
- CFunction (functional disorders in the patho-physiological sense)
- DInterventions
- A
77SNOMED CT concepts are organized into 19 hierarchies that includes
- Adisease, interventions
- Bsymptoms, diagnoses
- Cmorphology, etiology
- Dmedications, findings
78Semantic 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- ATrue
- BFalse
79Data Quality is required to be maintained by going through the data periodically (select the following which applies).
- Ascrubbing it
- Bdestroying it
- Cstandardizing it
- D updating it
80Understanding the fundamental principles embodied within the knowledge, utilizing knowledge to make sense and have an insight of what is happening
- AWisdom
- BKnowledge
- CData
- DInformation
81A right breast neoplasm in the anatomical site of 5:00 would be given the code of _________
- AC50.30
- BC50.80
- CC50.51
- DC50.31
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- Description
- Quiz on HIM CODING THEORY TEST, created by Dwayne Campbell on 20/10/2014.
- Author
- Dwayne Campbell
- Language
- English
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- 263
- History
- Created on 20 Oct 2014 · updated on 27 Mar 2016
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