HIM 1103 MODULE 1-6 STUDY GUIDE QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026

HIM 1103 MODULE 1-6 STUDY GUIDE QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026 Coding - Answers Taking documentation given by a physician and translating that documentation into alphanumerical codes for diagnosis documented and for any treatment documented in the patient chart Codes are used for___ - Answers Billing Medicare, Medicaid, and commercial insurance companies for payment; also for reporting statistics and reports to the state and federal government ICD 10 CM - Answers Alphanumeric coding system used for inpatient and outpatient diagnosis coding; have between 3-7 characters ICD 10 PCS - Answers Coding system used for inpatient procedure coding ONLY; Contains 7 alphanumeric characters CPT and HCPCS - Answers 5 digit numerical coding system used for outpatient procedure coding ONLY Encoder - Answers Software's that help coders find codes more efficiently than using a book Coding Software's we will use - Answers 3M Encoder and Quantim/Clintegrity Encoder ICD-10 stands for: - Answers International Classification of Diseases, 10th revision ICD-10-CM Coding Book is divided into____ - Answers Alphabetic index; Tabular List Alphabetic Index - Answers An alphabetic list of terms and their codes; never finalize a code after locating it in this section Tabular List - Answers A structured list of codes divided by chapters based on body system and condition; Contains categories, subcategories, and codes The ICD-10-Cm utilizes a____to allow for future expansion; used for if a code has less than 7 characters. - Answers Placeholder character X [ ]Brackets are used in the Tabular List to enclose - Answers Synonyms, alternative wording, or explanatory phrases. [ ]Brackets are used in the Alphabetic Index to identify - Answers Manifestation codes ( )Parenthesis are used in both the Tabular List and the Alphabetic Index to__ - Answers Enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number Excludes 1 Note in ICD 10 CM - Answers Indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note Excludes 2 note in ICD 10 CM - Answers Indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time Selection of a full code, including laterality and any applicable 7th character can only be done in the___ - Answers Tabular List Abstracting - Answers Data extraction from documentation in the medical record that creates an overview of the patient's visit; The data is then entered into a software system and converted to codes or analyzed for other purposes Accreditation - Answers A voluntary process that a facility undergoes for a review of their performance and adherence to policies by an independent organization created for the purpose of evaluation; May mean that an organization has met criteria established by an outside organization that meets standards set by an organization; usually reviewed on a regularly basis Acute Care - Answers Care given to a patient on a limited basis as an inpatient in a hospital setting APC Grouper - Answers The software used for the Ambulatory Payment Classification payment system; APC is used for outpatient coding and billing using CPT and HCPCS codes. AAPC (American Academy of Professional Coders) - Answers A national membership organization that provides credentials, education, and coding information to medical coders in all settings; AHIMA (American Health Information Management Association) - Answers A national membership organization that provides credentials, education, and coding information for health information management, health information systems, the revenue cycle, and medical coders in all settings. They also focus on specialized and new areas of the Health Information field such as risk management, clinical documentation improvement, and quality analysis. AHIMA also provides Virtual Lab tools for accredited schools AHA (American Hospital Association) - Answers The national trade membership organization that services individual healthcare providers and hospital healthcare organizations. AMA (American Medical Association) - Answers The national trade membership organization for physicians. this organization also assists in legislative matters for the medical profession. CMS (Centers for Medicare and Medicaid Services) - Answers A department that has oversight of healthcare policy in the US. It also has oversight of the federal Medicare program and the federal part of the Medicaid program. This is a part of the Department of Health and Human services of the federal government Charge Master - Answers Software or forms that contain itemized lists of cost of every service and supply a facility provides for their patients. One person is normally designated to keep the charge master information up to date and accurate Chart Deficiency System - Answers A manual or computerized system used by a facility to track documentation or signatures that are missing for a patient's chart. A staff person goes through the chart and looks for missing documentation, signatures, dates, or times required for the chart to be legal. Missing information is then entered into the software system or manually in forms and sent to whoever is responsible to provide the missing information Clinical or Medical Coding - Answers Coding conducted to assign numeric and alphanumeric codes to diagnostic and procedural documentation Coding Specialist - Answers The health information staff that are responsible for assigning numeric and alphanumeric codes to diagnostic and procedural documentation CAHIIM (Commission on Accreditation for Health Informatics and Information Management Education) - Answers CAHIIM is the accrediting organization that oversees educational programs in higher education for health information management Comorbidity - Answers A medical diagnosis that is present as well as the principle the patient's treatment and length of stay. An example is diabetes which must be managed carefully if the patient is admitted for COPD Exacerbation and needs steroids. Steroids impact diabetes and therefore these must be managed. EX. Fever, Diabetes Mellitus, Dehydration, etc. DRG (Diagnosis Related Group) - Answers A formula created by the federal government (CMS) and adopted by other payers as a way to determine payment for an inpatient stay. Related diagnosis are grouped together because management and treatment would be similar and interrelated and tend to incur similar cost and length of stay. Each diagnostic related group is assigned a number which factors into the formula which determines the cost of the inpatient stay DRG Grouper - Answers Software that automatically takes the codes entered by the coding specialist and organizes them into the proper DRG based on the principal diagnosis, the secondary diagnoses, the additional diagnosis, and the procedures Encoder - Answers Specially designed software that helps the coding specialist assign diagnostic and procedure codes in accordance with the guidelines and rules of each coding system Global Surgery Payment System - Answers A payment made for a surgical procedure which includes all aspects of the surgery from diagnosis through post procedural care. One payment is made which includes all aspects of the care for the diagnoses HIM (Health Information Management) - Answers The allied health profession that is responsible for the management of all health information for healthcare given to patients. This management includes accuracy, legality, privacy, timeliness, and availability HIT (Health Information Technology) - Answers The technical aspect of Health Information Management. This includes coding, data quality, abstracting, registration, auditing, storage of information, and aligning with regulations and guidelines. HIPAA (Health Insurance Portability and Accountability Act of 1996) - Answers Legislation implemented by the federal government to oversee privacy, fraud, abuse, continuity of health care, reduce health care costs, preexisting medical conditions, and identity theft. There are many HIPAA guidelines, especially for privacy, that all HIM and HIT employees must abide by TJC (The Joint Commission) - Answers A private, not-for-profit agency that evaluates hospitals and healthcare organizations based on pre-determined standards and criteria. If standards and criteria are me, the facility is granted Joint Commission accreditation. This is an indication that the facility is meeting high standards MPI (Masters Patient Index) - Answers A database created to house the patient name and identifying information for each facility. Each facility is responsible for their on MPI of every patient who has ever been admitted and treated by the facility Principal Diagnosis - Answers The disease or condition that was present on admission to an inpatient stay that was deemed to be the reason for admission after study of the entire chart. Principal Procedure - Answers A procedure performed in an inpatient stay for the treatment of a condition or complication. The main procedure performed and often tied to the Principal Diagnosis. ROI (Release of Information) - Answers An aspect of health information management which allows for the legal release of patient information to another party or to the patient RAC (Revenue Audit Contractor) - Answers An outside contractor hired by Medicare to audit coded accounts of patients for improper coding or billing in the Medicare program. SNOMED - CT - Systemized Nomenclature of Medicine Clinical Terminology - Answers Clinical Terms. This system creates standardized terminology of patient information; Specialized coding systems used in addition to the three main coding systems of ICD 10-CM, ICD 10 PCS,and CPT CDT - Answers The coding classification system used for dentistry HCPCS Level II Codes - Answers Also called National Codes and are maintained by CMS. these codes (not Level I CPT codes) are used to charge for medical services, equipment, and supplies. DSM-V-Diagnostic and Statistical Manual of Mental Disorders - Answers A set of codes used in billing for the treatment of patients with substance abuse disorders and mental disorders. These codes are designed to help the payer understand better the nature of what is being treated. This coding system is built based on five "groups" called, Axis I, Axis II, Axis III, Axis IV, and Axis V. These grouping give detail to the choice of diagnosis and treatment AHIMA is the only organization____ - Answers That combines credentials with a college degree In order to sit for the AHIMA RHIT exam, the applicant____ - Answers Must have completed a CAHIIM accredited Health Information Associate Degree program Coding Credentials: - Answers CCA, CCS, CCS-P Academic Credentials (Require specific degrees from accredited colleges): - Answers RHIT, RHIA Professional Certifications - Answers CHPS, CHDA, CDIP Medical Coding Credentials - Answers CPC, COC, CIC, CPP-P, CRC Medical billing Certifications - Answers CPB Medical Auditing Certification - Answers CPMA Medical Compliance Certification - Answers CPCO Physician Practice Manager Certification - Answers CPPM Diagnosis - Answers A patients condition, illness, or injury as determined by the physician and documented in the patient's chart Medical Necessity - Answers A diagnosis that provides a valid health care reason for services provided for a patient Risk Factor - Answers A condition or illness that increases a patient's susceptibility to a disease or condition Sign - Answers Evidence via laboratory results, test results, x rays, etc. of a disease or a condition a patient has Symptom - Answers An abnormal state or sensation that a patient states they are experiencing Supporting Documentation - Answers The data in a patient's chart that supports the codes chosen Complication - Answers An unexpected condition that develops after a surgery, procedure, test, or treatment while a patient is in the hospital Exacerbation - Answers An increase in the severity of a condition or illness that the patient already has Adverse Effect of: - Answers When a drug , medicine, or test material causes a reaction in the patient Sequela - Answers A late effect of one condition or disease that causes a second condition NEC (Not Elsewhere Classified) - Answers Details in the documentation that are not described in any other code in the code book NOS (Not Otherwise Specified) - Answers The absence of details in the documentation that might be used to code more specifically Other Specified - Answers Information that the physician has documented but is not found in the code descriptions available Etiology - Answers A physician's study of and determination of the cause of a disease or condition Epynom - Answers A condition or disease named after the person who discovered it. Manifestation - Answers A condition that is caused and is the result of a previous condition Co-Morbidities - Answers A separate disease or condition that is separate from the disease or condition which has caused an inpatient admission Unbundling - Answers Coding a procedure in multiple codes when one code has been provided in the code book