Introduction to Health Information Technology
Exam Materials
Course Introduction
Introduction to Health Information Technology provides students with a comprehensive overview of the systems and processes used to collect, manage, and secure healthcare data in modern medical environments. The course explores key concepts such as electronic health records (EHRs), health informatics standards, data privacy and security regulations (including HIPAA), and the technological tools that support efficient patient care. Students will also examine the role of health IT professionals in improving healthcare delivery, supporting clinical decision-making, and facilitating communication among providers, patients, and payers. Emphasis is placed on understanding current trends, challenges, and ethical considerations associated with health information technology in diverse healthcare settings.
Recommended Textbook
The Complete Diagnosis Coding Solution 3rd Edition by Shelley Safian
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23 Chapters
1144 Verified Questions
1144 Flashcards
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Page 2
Chapter 1: Introduction to Diagnostic Coding
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Sample Questions
Q1) Unbundling is an example of ________.
A) payment
B) fraud
C) coverage
D) penalties
Answer: B
Q2) A ____________ is a subjective sensation as expressed by the patient.
A) symptom
B) treatment
C) diagnosis
D) condition
Answer: A
Q3) The abbreviation AP stands for _____________.
A) anteroposterior
B) posteroanterior
C) anterior oblique
D) posterior oblique
Answer: A
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Chapter 2: Introduction to ICD-10-CM
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Sample Questions
Q1) When coding a late effect from a pregnancy-related condition, how long is the postpartum period?
A) Immediately after delivery
B) 2 weeks
C) 4 weeks
D) 6 weeks
Answer: D
Q2) Which of the following external cause codes is used to report the status of a patient who was injured while participating in a volunteer activity?
A) Y99.1
B) Y99.2
C) Y99.3
D) Y99.4
Answer: B
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Chapter 3: General Guidelines and Notations
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Sample Questions
Q1) When coding a differential diagnosis, the coder will:
A) code two conditions, and the one documented first is the principal diagnosis.
B) code two conditions, and the one documented second is the principal diagnosis.
C) code two conditions, and either code can be assigned as the principal diagnosis.
D) only code symptoms because there is no definitive diagnosis to assign as principal.
Answer: C
Q2) Which of the following codes indicates the highest level of specificity available for a dislocation of a sacroiliac and sacrococcygeal joint, subsequent encounter?
A) S33.D
B) S33.2A
C) S33.2XXD
D) S33.3XXD
Answer: C
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5
Chapter 4: Coding Infectious Diseases
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Sample Questions
Q1) Corrina's skin test for tuberculosis was positive, but she does not have the disease. Report this with code:
A) Z86.11.
B) R76.11.
C) B90.9.
D) A15.7.
Q2) What are hookworms, pinworms, and tapeworms examples of?
A) Bacteria
B) Fungi
C) Parasites
D) Viruses
Q3) Hailee Samuels has tested HIV positive but has no signs or symptoms. Report her diagnosis with code:
A) Z71.7.
B) R75.
C) Z21.
D) B20.
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6
Chapter 5: Coding Neoplasms
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Sample Questions
Q1) When normal cells mutate, they create a:
A) benign tumor.
B) malignant tumor.
C) neoplasm.
D) All of these
Q2) What is the correct code assigned for intraductal carcinoma in situ of the right breast?
A) D05.90
B) D05.11
C) D05.12
D) D05.81
Q3) All neoplasms are classified according to which chapter in the ICD-10-CM coding manual?
A) 2
B) 3
C) 4
D) 5
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Page 7
Chapter 6: Coding Diseases of the Blood and Immune Mechanism
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Sample Questions
Q1) Which common blood test is used to identify a clotting disorder?
A) Platelet count
B) Potassium
C) Prothrombin time
D) Sodium
Q2) Bobby Joe Hill was brought to the ER with weakness. After the ER physician completed some blood tests, he determined that Bobby Joe has idiopathic aplastic anemia. What is/are the correct code(s) to report?
A) D61.3
B) D61.89
C) R53.1, D61.3
D) R53.1, D61.89
Q3) What is the correct code for neonatal thrombocytopenia due to exchange transfusion?
A) D69.41
B) D69.42
C) P61.0
D) P61.1
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Chapter 7: Coding Conditions of the Endocrine and Metabolic Systems
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Sample Questions
Q1) What does the abbreviation DI stand for?
A) Diabetes iatrogenic
B) Diabetes insipidus
C) Diabetic insulin
D) Diabetic infection
Q2) What is the correct code assigned for type 1 DM with diabetic neuralgia?
A) E10.40
B) E10.41
C) E10.42
D) E10.49
Q3) What is/are the correct code(s) assigned for a type 2 diabetic patient with hypoglycemia?
A) E11.641
B) E11.649
C) E11.641, E16.2
D) E11.649, E16.3
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9
Chapter 8: Coding Mental and Behavioral Disorders
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Sample Questions
Q1) People with a relative who has schizophrenia are how many times more likely to develop schizophrenia themselves?
A) 5
B) 10
C) 20
D) 50
Q2) What is the correct code for cannabis abuse with intoxication and perceptual disturbance?
A) F12.120
B) F12.121
C) F12.122
D) F12.129
Q3) What is the correct code assigned for a patient with claustrophobia?
A) F40.240
B) F40.241
C) F40.242
D) F40.243
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Chapter 9: Coding Nervous System Conditions
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Sample Questions
Q1) Which of the following controls coordination and maintaining balance?
A) Basal ganglia
B) Hypothalamus
C) Cerebral meninges
D) Cerebellum
Q2) Which layer of the meninges is the outermost?
A) Arachnoid mater
B) Basal mater
C) Dura mater
D) Pia mater
Q3) What is the correct code assigned for a patient with an intractable abdominal migraine?
A) G43.A0
B) G43.A1
C) G43.D0
D) G43.D1
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11
Chapter 10: Coding Diseases of the Eye and Adnexa
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Sample Questions
Q1) What are the correct codes for a patient with proliferative bilateral retinopathy with bilateral bullous keratopathy?
A) H35.23, H18.10
B) H35.23, H18.11
C) H35.23, H18.12
D) H35.23, H18.13
Q2) Which of the following is not a sign or symptom of hypertensive retinopathy?
A) Headache
B) Double vision
C) Vision loss
D) Nausea
Q3) Which is the first stage of diabetic retinopathy?
A) Mild nonproliferative retinopathy
B) Moderate nonproliferative retinopathy
C) Severe nonproliferative retinopathy
D) Proliferative retinopathy
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12
Chapter 11: Coding Diseases of the Auditory System Ears
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Sample Questions
Q1) What is the correct code for mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side?
A) H90.42
B) H90.5
C) H90.72
D) H90.8
Q2) What is the correct code for chronic serous otitis media of the left ear?
A) H65.21
B) H65.22
C) H65.31
D) H65.32
Q3) Which part of the ear is the most complex?
A) Inner ear
B) Middle ear
C) External ear
D) All of these
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13
Chapter 12: Coding Circulatory Conditions
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Sample Questions
Q1) Which of these conditions is an irregular heartbeat?
A) Angina
B) Cardiac arrest
C) Dyspnea
D) Arrhythmia
Q2) What is the correct code for a fast heartbeat?
A) R00.0
B) R00.1
C) R00.2
D) R00.8
Q3) Which part of the heart is known as the bundle of His?
A) AV bundle
B) SA bundle
C) Mitral valve
D) Bicuspid valve
Q4) What is the correct code for a slow heartbeat?
A) R00.0
B) R00.1
C) R00.2
D) R00.8
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Chapter 13: Coding Respiratory Conditions
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Sample Questions
Q1) Which of the following is not a paranasal sinus?
A) Maxillary
B) Frontal
C) Ethmoidal
D) Septal
Q2) What is the correct code for a patient who has a sphenoidal polyp of the sinus?
A) J33.0
B) J33.1
C) J33.8
D) J33.9
Q3) Which of the following is used to remove fluid from the pleura?
A) CT
B) Thoracentesis
C) Spirometer
D) Scintiphotography
Q4) What is the correct code for pneumonitis due to inhalation of oils and essences?
A) J69.0
B) J69.1
C) J69.8
D) J70.0
Page 15
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Chapter 14: Coding Diseases of the Digestive System
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Sample Questions
Q1) What is the correct code for parastomal hernia, with gangrene?
A) K43.4
B) K43.5
C) K43.6
D) K43.7
Q2) What is the correct code for an acute gastric ulcer with perforation?
A) K25.0
B) K25.1
C) K25.2
D) K25.3
Q3) What is the correct code for chronic lobular hepatitis?
A) K73.0
B) K73.1
C) K73.2
D) K73.8
Q4) What is the correct code for an acute recurrent sialoadenitis?
A) K11.2
B) K11.21
C) K11.22
D) K11.23
Page 16
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Chapter 15: Coding Diseases of the Integumentary System
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Sample Questions
Q1) What is another name for baldness?
A) Alopecia
B) Trichotillomania
C) Albinism
D) Hirsutism
Q2) Which of the following lesions is a large vesicle that is filled with fluid?
A) Macule
B) Nevus
C) Scale
D) Bulla
Q3) Which of the following is the code assigned for nail dystrophy?
A) L60.0
B) L60.1
C) L60.2
D) L60.3
Q4) As a coder, what do you need to know when coding a pressure ulcer?
A) Anatomical location
B) Depth of lesion
C) Both anatomical location and depth of lesion
D) Neither anatomical location nor depth of lesion
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Chapter 16: Coding Muscular Conditions
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Sample Questions
Q1) Which of the following is not an upper leg muscle?
A) Adductor brevis
B) Gracilis
C) Transverse perineal muscle, deep
D) Pectineus
Q2) Which of the following muscles raises a body part?
A) Levator muscle
B) Intrinsic muscle
C) Extensor muscle
D) Flexor muscle
Q3) Which of the following injuries is caused by an overstretched ligament?
A) Contusion
B) Sprain
C) Strain
D) Tear
Q4) Which of the following muscles straightens an arm or leg?
A) Abductor muscle
B) Adductor muscle
C) Extensor muscle
D) Flexor muscle
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Chapter 17: Coding Skeletal Conditions
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Sample Questions
Q1) How many pairs of ribs does a human have?
A) 6
B) 8
C) 10
D) 12
Q2) Which set of ribs are also called the floating ribs?
A) 1-7
B) 8-10
C) 11-12
D) None of these
Q3) Which of the following seventh characters is used to show that the patient was seen for an initial encounter for treatment of a fracture?
A) A
B) D
C) G
D) K
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Page 19
Chapter 18: Coding Diseases of the Urinary System
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Sample Questions
Q1) Which of the following is a true statement for a coder?
A) If a patient has both hypertension and CKD, the coder is to assume a cause-and-effect relationship.
B) If a patient has both hypertension and CKD, the coder cannot assume a cause-and-effect relationship.
C) If a patient has both hypertension and CKD, the coder will only code hypertension.
D) If a patient has both hypertension and CKD, the coder will only code CKD.
Q2) What shape is the prostate?
A) Almond
B) Chestnut
C) Pistachio
D) Peanut
Q3) What is the correct code assigned for a patient with an abscess of the bladder?
A) N30.8
B) N30.80
C) N30.81
D) N30.91
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Chapter 19: Coding for Obstetrics and Gynecology
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Sample Questions
Q1) Which of the following terms reports how many times a woman has been pregnant?
A) Abortus
B) Gravida
C) Para
D) Parity
Q2) A preterm baby is born before which completed week of gestation?
A) 34
B) 35
C) 36
D) 37
Q3) When coding for the mother, every encounter that results in the birth of a baby requires how many codes?
A) 1
B) 2
C) 3
D) 4
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Page 21
Chapter 20: Coding Congenital and Pediatric Conditions
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Q1) What is the correct code for a newborn with sepsis due to Staphylococcus aureus?
A) P36.19
B) P36.2
C) P36.3
D) P36.39
Q2) Which of the following is used to obtain placental tissue samples?
A) Amniocentesis
B) Karyotype
C) Chorionic villus sampling
D) Pedigree
Q3) When does a baby get his or her own chart?
A) At conception
B) During the last trimester of the pregnancy
C) At birth
D) After the two-week well-child check
Q4) Which of the following describes an irregular structural development?
A) Anomaly
B) Congenital
C) Malformation
D) Preexisting
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Chapter 21: Coding Injuries, Poisonings, and Certain Other
Consequences of External Causes
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Sample Questions
Q1) When a bleeding area has coagulated into a blood clot, it is known as a(n):
A) abrasion.
B) contusion.
C) hematoma.
D) wound.
Q2) What is the correct code for a subsequent encounter for postprocedural cardiogenic shock?
A) T81.11
B) T81.11XA
C) T81.11XD
D) T81.11XS
Q3) Which of the following is used to estimate the extent of burns?
A) Rule of fives
B) Rule of nines
C) Rule of sides
D) Rule of skin
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Chapter 22: Factors Influencing Health Status and Contact
With Health Services
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Sample Questions
Q1) What is the correct code for an office visit to screen a patient for anemia?
A) Z13.88
B) Z13.0
C) Z13.9
D) Z13.6
Q2) Carina Friday delivered a healthy newborn six weeks ago and is now presenting for a postpartum follow-up visit. What is the correct code assignment?
A) Z39.0
B) Z39.1
C) Z39.2
D) O80
Q3) What is/are the correct code(s) for an adult patient with a BMI of 46 who is receiving dietary counseling?
A) Z71.3
B) Z71.3, Z68.41
C) Z71.3, Z68.42
D) Z71.3, Z68.43
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Page 24
Chapter 23: Hospital Inpatient Diagnosis Coding
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Sample Questions
Q1) The UHDDS is a collection of specific data gathered about hospital patients:
A) on admission.
B) on discharge.
C) before surgery.
D) postoperatively.
Q2) Mary Matthews was found to have a breast lump during a mammogram last month. She is admitted today for a breast biopsy of her left breast. The pathology report returns with infiltrating papillary breast carcinoma of the left breast. Mary's mother had breast cancer in her fifties. What is the correct code assignment?
A) D05.12
B) D05.12, Z80.3
C) C50.312
D) C50.912, Z80.3
Q3) Which of the following parts of Medicare is paid under the DRG system?
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
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