HIM 1423 Final Exam Questions and Answers Latest Update 2025 Graded A+
The standard claim form used by hospitals to request reimbursement for IP & OP procedures or services
is called - Answers UB-04
What is the difference between morbidity and mortality? - Answers Morbidity refers to disease and
mortality refers to death
What is MetaData? - Answers Data about data
What does parallel, phased, direct cutover have to do with IT? - Answers 3 ways to convert from paper
to EHR
Parallel - Answers To run the old and new EHR programs at the same time
Phased - Answers This is where two separate elements of a new information technology system are
implemented over time
Direct Cut-over - Answers The abrupt immediate implementation of new system replace an existing
system
True or False: The Ambulatory Payment Classification (APC) includes services for hospital outpatient
services. - Answers True
What organization is responsible for the official coding guidelines of ICD-9-CM?
A. AHA
B. AMA
C. CMS
D. AHIMA
E. NCHS - Answers A. American Hospital Association
True or False: A template is a term referring to the narrative nature of clinical documentation. - Answers
False
What is an input device and what are some examples? - Answers An input device is a device of inputting
data into an IT system. Such as keyboard or mouse
What are the three types of electronic signatures? - Answers Digitized, electronic and digital
What is the process called for searching for data in a data warehouse? - Answers Data mining
All of the following are considered hardware except: - Answers Database
,What is the difference between data and information? - Answers Data are facts while information has
meaning.
The data is useful. - Answers Relevancy
The data is up to date. - Answers Currency
The data is correct. - Answers Accuracy
The data is reliable. - Answers Consistency
Who accredits SDO's? - Answers American National Standards Institute
A style of computer interface in which typed commands are replaced by images (icons) that represent
tasks. - Answers GUI - graphical user interface
What are the five rights of BC-MAR? - Answers Right drug, patient, dose, time, route
What is the difference between an encoder and a grouper? - Answers A grouper assigns MS-DRGs and
an encoder assigns ICD and CPT codes.
Who developed ICD-9 and ICD-10? - Answers World Health Organization
What coding system do you use to code procedures of inpatients? - Answers ICD-10-PCS
In healthcare, who is the third party payer? - Answers Insurance
First party - Patient
Second party - provider
What code provides a means to classify environmental events, circumstances and conditions as the
cause of injury, poisoning and other adverse effect? - Answers E Codes
Who maintains the CPT system? - Answers American Medical Association
In ICD-10-PCS, what letters are not in use? - Answers I's and O's
What is ICD-O-3? - Answers A classification system of oncology diseases.
What part of Medicare coverage pays for hospital care? - Answers Part A
What part of Medicare coverage pays for prescription drugs? - Answers Part D
What is Medicare Part C? - Answers Medicare Advantage
What is the name of the program that provides insurance to children up to age 19? - Answers CHIP or
SCHIP
,What is OASIS used for? - Answers Core data elements are collected to measure home healthcare
patient outcomes
True or False: The chargemaster a coding system. - Answers False
Who publishes the Coding Clinic? - Answers American Hospital Association (AHA)
Who establishes the annual compliance plans for the healthcare industry? - Answers The OIG
True or False: AHIMA has developed Standards of Ethical Coding. - Answers True
Which of the following is a type of network security? - Answers Firewall
The 3 elements of a security program are ensuring data availability, protection and - Answers Integrity
The HIM department has received a research request from the CQI Committee that plans to review
charts for all patients having a laparoscopic cholecystecomy for the months of March and April, 2010.
What would be the best source for locating the needed records? - Answers Procedure Index
DSM-IV is used most frequently in what type of healthcare setting? - Answers Mental health
The principal diagnosis is - Answers condition established after study, to be chiefly responsible for
admission of the patient to the hospital
Which of the following is a standard data set used to collect data in acute care facilities? - Answers
Uniform Hospital Discharge Data Set (UHDDS)
In a cancer registry, the accession number is - Answers The number assigned to each patient as he/she is
entered into a cancer registry
What does an audit trail check for? - Answers Unauthorized access to a system
A cancer program is surveyed by - Answers American College of Surgeons
What is a population-based registry? - Answers includes information from more than one facility in a
particular geopolitical area, such as a state or region
Which of the following is used to report the durable medical equipment, healthcare supplies,products,
and services provided to patients by healthcare professionals? - Answers HCPCS
When a service is not considered medically necessary based on the reason for encounter, the patient
should be provided with a ______________________ indicating that Medicare might not pay and that
the patient might be responsible for the entire charge. - Answers Advance Beneficiary Notice of Non-
coverage
The categories of patients (type and volume) treated by a hospital which represents the complexity the
hospital's patient population is called: - Answers Case-mix
, Final review during EHR implementation to ensure that all tests have been performed and all issues have
been resolved; when a maintenance contract becomes effective is called this type of testing: - Answers
Acceptance testing
Which of the following is not performed in the EHR? - Answers Assembly
What is case finding? - Answers identify patients who have been seen or treated in a facility for a
particular disease or condition for inclusion in a registry.
What is the prospective payment system used in long-term care? - Answers RUG's
Dr.Smith is entering a medication order in a CPOE. A window pops up with the following message:
Patient is on beta-blocker, which is a contraindication for this medication. Do you want to order this
medication? Yes or No.
This is an example of a(n): - Answers Alert
Data that are collected from individual records and then combined are referred to as: - Answers
Aggregate data
What data set is used to collect information on hospital trauma? - Answers DEEDS
True or False: Nosology is the branch of medical science that deals with classification systems. - Answers
True
Which of the following provides the most comprehensive controlled vocabulary for coding the contents
of a patient record? - Answers SNOMED
What is the CMS-1500? - Answers The universal insurance claim form developed and approved by the
AMA and CMS; physicians use it to bill Medicare, Medicaid, and private insurers for services provided
Entitlement program that oversees medical assistance for individuals and families with low incomes and
limited resources; jointly funded between state and federal governments. - Answers Medicaid
What is a remittance advice? - Answers a statement sent to the provider to explain payments made by
third-party payers.
The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or
treatment of illness or injury consistent with generally accepted standards of care is - Answers Medical
necessity
An organization contracted by the government to eliminate fraud and abuse and recover Medicare
overpayments. - Answers RAC
What is MDS 3.0? - Answers Federally maintained standard assessment form that Medicare- and/or
Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home
residents.
The standard claim form used by hospitals to request reimbursement for IP & OP procedures or services
is called - Answers UB-04
What is the difference between morbidity and mortality? - Answers Morbidity refers to disease and
mortality refers to death
What is MetaData? - Answers Data about data
What does parallel, phased, direct cutover have to do with IT? - Answers 3 ways to convert from paper
to EHR
Parallel - Answers To run the old and new EHR programs at the same time
Phased - Answers This is where two separate elements of a new information technology system are
implemented over time
Direct Cut-over - Answers The abrupt immediate implementation of new system replace an existing
system
True or False: The Ambulatory Payment Classification (APC) includes services for hospital outpatient
services. - Answers True
What organization is responsible for the official coding guidelines of ICD-9-CM?
A. AHA
B. AMA
C. CMS
D. AHIMA
E. NCHS - Answers A. American Hospital Association
True or False: A template is a term referring to the narrative nature of clinical documentation. - Answers
False
What is an input device and what are some examples? - Answers An input device is a device of inputting
data into an IT system. Such as keyboard or mouse
What are the three types of electronic signatures? - Answers Digitized, electronic and digital
What is the process called for searching for data in a data warehouse? - Answers Data mining
All of the following are considered hardware except: - Answers Database
,What is the difference between data and information? - Answers Data are facts while information has
meaning.
The data is useful. - Answers Relevancy
The data is up to date. - Answers Currency
The data is correct. - Answers Accuracy
The data is reliable. - Answers Consistency
Who accredits SDO's? - Answers American National Standards Institute
A style of computer interface in which typed commands are replaced by images (icons) that represent
tasks. - Answers GUI - graphical user interface
What are the five rights of BC-MAR? - Answers Right drug, patient, dose, time, route
What is the difference between an encoder and a grouper? - Answers A grouper assigns MS-DRGs and
an encoder assigns ICD and CPT codes.
Who developed ICD-9 and ICD-10? - Answers World Health Organization
What coding system do you use to code procedures of inpatients? - Answers ICD-10-PCS
In healthcare, who is the third party payer? - Answers Insurance
First party - Patient
Second party - provider
What code provides a means to classify environmental events, circumstances and conditions as the
cause of injury, poisoning and other adverse effect? - Answers E Codes
Who maintains the CPT system? - Answers American Medical Association
In ICD-10-PCS, what letters are not in use? - Answers I's and O's
What is ICD-O-3? - Answers A classification system of oncology diseases.
What part of Medicare coverage pays for hospital care? - Answers Part A
What part of Medicare coverage pays for prescription drugs? - Answers Part D
What is Medicare Part C? - Answers Medicare Advantage
What is the name of the program that provides insurance to children up to age 19? - Answers CHIP or
SCHIP
,What is OASIS used for? - Answers Core data elements are collected to measure home healthcare
patient outcomes
True or False: The chargemaster a coding system. - Answers False
Who publishes the Coding Clinic? - Answers American Hospital Association (AHA)
Who establishes the annual compliance plans for the healthcare industry? - Answers The OIG
True or False: AHIMA has developed Standards of Ethical Coding. - Answers True
Which of the following is a type of network security? - Answers Firewall
The 3 elements of a security program are ensuring data availability, protection and - Answers Integrity
The HIM department has received a research request from the CQI Committee that plans to review
charts for all patients having a laparoscopic cholecystecomy for the months of March and April, 2010.
What would be the best source for locating the needed records? - Answers Procedure Index
DSM-IV is used most frequently in what type of healthcare setting? - Answers Mental health
The principal diagnosis is - Answers condition established after study, to be chiefly responsible for
admission of the patient to the hospital
Which of the following is a standard data set used to collect data in acute care facilities? - Answers
Uniform Hospital Discharge Data Set (UHDDS)
In a cancer registry, the accession number is - Answers The number assigned to each patient as he/she is
entered into a cancer registry
What does an audit trail check for? - Answers Unauthorized access to a system
A cancer program is surveyed by - Answers American College of Surgeons
What is a population-based registry? - Answers includes information from more than one facility in a
particular geopolitical area, such as a state or region
Which of the following is used to report the durable medical equipment, healthcare supplies,products,
and services provided to patients by healthcare professionals? - Answers HCPCS
When a service is not considered medically necessary based on the reason for encounter, the patient
should be provided with a ______________________ indicating that Medicare might not pay and that
the patient might be responsible for the entire charge. - Answers Advance Beneficiary Notice of Non-
coverage
The categories of patients (type and volume) treated by a hospital which represents the complexity the
hospital's patient population is called: - Answers Case-mix
, Final review during EHR implementation to ensure that all tests have been performed and all issues have
been resolved; when a maintenance contract becomes effective is called this type of testing: - Answers
Acceptance testing
Which of the following is not performed in the EHR? - Answers Assembly
What is case finding? - Answers identify patients who have been seen or treated in a facility for a
particular disease or condition for inclusion in a registry.
What is the prospective payment system used in long-term care? - Answers RUG's
Dr.Smith is entering a medication order in a CPOE. A window pops up with the following message:
Patient is on beta-blocker, which is a contraindication for this medication. Do you want to order this
medication? Yes or No.
This is an example of a(n): - Answers Alert
Data that are collected from individual records and then combined are referred to as: - Answers
Aggregate data
What data set is used to collect information on hospital trauma? - Answers DEEDS
True or False: Nosology is the branch of medical science that deals with classification systems. - Answers
True
Which of the following provides the most comprehensive controlled vocabulary for coding the contents
of a patient record? - Answers SNOMED
What is the CMS-1500? - Answers The universal insurance claim form developed and approved by the
AMA and CMS; physicians use it to bill Medicare, Medicaid, and private insurers for services provided
Entitlement program that oversees medical assistance for individuals and families with low incomes and
limited resources; jointly funded between state and federal governments. - Answers Medicaid
What is a remittance advice? - Answers a statement sent to the provider to explain payments made by
third-party payers.
The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or
treatment of illness or injury consistent with generally accepted standards of care is - Answers Medical
necessity
An organization contracted by the government to eliminate fraud and abuse and recover Medicare
overpayments. - Answers RAC
What is MDS 3.0? - Answers Federally maintained standard assessment form that Medicare- and/or
Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home
residents.
