HIM 1423 Final Exam Review Questions
and Answers 2025
The standard claim form used by hospitals to request reimbursement for IP & OP
procedures or services is called - Correct Ans-UB-04
What is the difference between morbidity and mortality? - Correct Ans-Morbidity refers
to disease and mortality refers to death
What is MetaData? - Correct Ans-Data about data
What does parallel, phased, direct cutover have to do with IT? - Correct Ans-3 ways to
convert from paper to EHR
Parallel - Correct Ans-To run the old and new EHR programs at the same time
Phased - Correct Ans-This is where two separate elements of a new information
technology system are implemented over time
Direct Cut-over - Correct Ans-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. - Correct Ans-True
What organization is responsible for the official coding guidelines of ICD-9-CM?
A. AHA
B. AMA
C. CMS
D. AHIMA
E. NCHS - Correct Ans-A. American Hospital Association
True or False: A template is a term referring to the narrative nature of clinical
documentation. - Correct Ans-False
What is an input device and what are some examples? - Correct Ans-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? - Correct Ans-Digitized, electronic
and digital
What is the process called for searching for data in a data warehouse? - Correct Ans-
Data mining
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All of the following are considered hardware except: - Correct Ans-Database
What is the difference between data and information? - Correct Ans-Data are facts while
information has meaning.
The data is useful. - Correct Ans-Relevancy
The data is up to date. - Correct Ans-Currency
The data is correct. - Correct Ans-Accuracy
The data is reliable. - Correct Ans-Consistency
Who accredits SDO's? - Correct Ans-American National Standards Institute
A style of computer interface in which typed commands are replaced by images (icons)
that represent tasks. - Correct Ans-GUI - graphical user interface
What are the five rights of BC-MAR? - Correct Ans-Right drug, patient, dose, time, route
What is the difference between an encoder and a grouper? - Correct Ans-A grouper
assigns MS-DRGs and an encoder assigns ICD and CPT codes.
Who developed ICD-9 and ICD-10? - Correct Ans-World Health Organization
What coding system do you use to code procedures of inpatients? - Correct Ans-ICD-
10-PCS
In healthcare, who is the third party payer? - Correct Ans-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? - Correct Ans-E
Codes
Who maintains the CPT system? - Correct Ans-American Medical Association
In ICD-10-PCS, what letters are not in use? - Correct Ans-I's and O's
What is ICD-O-3? - Correct Ans-A classification system of oncology diseases.
What part of Medicare coverage pays for hospital care? - Correct Ans-Part A
What part of Medicare coverage pays for prescription drugs? - Correct Ans-Part D
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What is Medicare Part C? - Correct Ans-Medicare Advantage
What is the name of the program that provides insurance to children up to age 19? -
Correct Ans-CHIP or SCHIP
What is OASIS used for? - Correct Ans-Core data elements are collected to measure
home healthcare patient outcomes
True or False: The chargemaster a coding system. - Correct Ans-False
Who publishes the Coding Clinic? - Correct Ans-American Hospital Association (AHA)
Who establishes the annual compliance plans for the healthcare industry? - Correct
Ans-The OIG
True or False: AHIMA has developed Standards of Ethical Coding. - Correct Ans-True
Which of the following is a type of network security? - Correct Ans-Firewall
The 3 elements of a security program are ensuring data availability, protection and -
Correct Ans-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? - Correct Ans-Procedure Index
DSM-IV is used most frequently in what type of healthcare setting? - Correct Ans-
Mental health
The principal diagnosis is - Correct Ans-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?
- Correct Ans-Uniform Hospital Discharge Data Set (UHDDS)
In a cancer registry, the accession number is - Correct Ans-The number assigned to
each patient as he/she is entered into a cancer registry
What does an audit trail check for? - Correct Ans-Unauthorized access to a system
A cancer program is surveyed by - Correct Ans-American College of Surgeons
What is a population-based registry? - Correct Ans-includes information from more than
one facility in a particular geopolitical area, such as a state or region
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Which of the following is used to report the durable medical equipment, healthcare
supplies,products, and services provided to patients by healthcare professionals? -
Correct Ans-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. - Correct Ans-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: - Correct Ans-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: - Correct Ans-Acceptance testing
Which of the following is not performed in the EHR? - Correct Ans-Assembly
What is case finding? - Correct Ans-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? - Correct Ans-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): - Correct Ans-Alert
Data that are collected from individual records and then combined are referred to as: -
Correct Ans-Aggregate data
What data set is used to collect information on hospital trauma? - Correct Ans-DEEDS
True or False: Nosology is the branch of medical science that deals with classification
systems. - Correct Ans-True
Which of the following provides the most comprehensive controlled vocabulary for
coding the contents of a patient record? - Correct Ans-SNOMED
What is the CMS-1500? - Correct Ans-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
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