HIM 1103 STUDY GUIDE QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026

HIM 1103 STUDY GUIDE QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026 Diagnosis - Answers A patient's 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 a laboratory results, test results, x rays, etc. of a disease or condition that 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. Eponym - Answers A condition or disease named after the person who discovered it. Manifestations - 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. Up coding - Answers Using a code that indicates a higher level service than the documentation indicates. Double Billing - Answers Sending a claim through twice for the same service and date. Abstracting - Answers Data extraction from documentation in the medical record that creates an overview of the patient's encounter. 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. It may also mean that an organization has met criteria established by an outside organization that meets standards set by the organization. These are usually reviewed on a regular timely 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. The APC system 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. Their website is . 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 such as Rasmussen College. . 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 U.S. 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 or alphanumeric codes to diagnostic and procedural documentation. Coding Specialist - Answers The health information staff that are responsible for assigning numeric or 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 a COPD Exacerbation and needs steroids. Steriods impact diabetes and therefore these must be managed. 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 or 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 diagnosis, 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 diagnosis. 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 - Answers Health Insurance Portability and Accountability Act of 1996 - 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 met, the facility is granted Joint Commission accreditation. This is an indication that the facility is meeting high standards.