Chapter 1-3 Review: 0ST-248

Every encounter between the patient and the health care professional must have at least _____ diagnosis code(s) and at least ___ procedure code(s)

1,1

Coding a sequela requires at least ________ codes.

2

What is the correct CPT code for a Laparoscopy, surgical; gastronomy, without construction of gastric tube?

43653

Linking

Confirming medical necessity by pairing at least one diagnosis code to at least one procedure code.

Section IV

Diagnostic Coding and Reporting Guidelines for Outpatient Services

Symbols

Marks, similar to emojis, that provide additional direction to use codes correctly and accurately

Signs

Measurable indicators of a patient's health status

Coding languages communicate information that is key to which of the following aspect(s) of the health care system?

Medical necessity, resources allocation, and reimbursement

"Code Also" note

Section 1. A. 17

Assume

Suppose to be the case, without proof; guess the intended details

What part of the ICD-10-CM code book do you use to confirm that a diagnostic code is accurate?

The Tabular List

Classification System

The category term used in health care to identify ICD-10-CM. CPT, ICD-10-PCS, and HCPCS Level II code sets

Treatment

The provision of medical care for a disorder or disease

In the ICD-10-CM Tabular List above the code K70.31 there is a notation. What is the notation?

Use additional code to identify alcohol abuse and dependence

The most important factor in coding is

accuracy of codes

All of the following would be considered a diagnostic "main term" except

acute

The first question you, as the professional coder, will need to ask is

for whom are you reporting?

The official guidelines for ICD-10-CM can usually be found int the

front of the code book

When ICD-10-CM codes support medical necessity

there was valid medical reason to provide care

The why justifies the

what

The why justifies the ______.

what

A procedure explains

what the provider did for the patient

A diagnosis explains

why the patient requires attention of the provider

Every patient encounter must have at least _____ reportable [codeable] reason why and at least _____ reportable [codebale] explanation of what.

1,1

Sequela

A cause-and-effect relationship between an original condition that has been resolved with a current condition, also known as the late effect.

Alphanumeric

A code consisting of both numbers and letters

Manifestation

A condition that develops as the result of another, underlying codition

Eponym

A disease or condition named for a person

Which of the following is an acute care facility?

A hospital

Official Guidelines

A listing of rules and regulations instructing how to use a specific code set accurately

Symptoms

A patient's subjective description of feeling

Diagnosis

A physician's determination pf a patient's condition, illness, or injury.

Co-mobordity

A separate condition or illness present in the same patient at the same time as another, unrelated condition or illness.

Procedure

Action taken, in accordance with the standards of care, by the physician to accomplish a predetermined objective (result); a surgical operation

Notations

Alerts and warnings that support more accurate use of codes in a specific code set

Which of the following would be an example of an eponym?

Arnold-Chiari disease

Tom is diagnosis herpes zoster, conjunctivitis. Which ICD-10-CM diagnosis code would you assign?

B02.31

Section I

Conventions, general coding guidelines and chapter specific guidelines

Which of the following is a full code description?

Cutaneous abscess of chest wall L02.213

Interpret

Explain the meaning of; convert a meaning from one language to another

IPPB machine would be an example of a term found in which Alphabetic Index

HCPCS Level II

Outpatient

Health care services provided to individuals without an overnight stay in the facility

Pneumonia would be an example of a term found in which Alphabetic Index?

ICD-10-CM

Which code book contains all of the codes to report the reason why the health care provider cared for the patient during a specific encounter

ICD-10-CM code book

Which code book contains all of the codes to report the reason why the health care provider cared for the patient during a specific encounter?

ICD-10-CM code book

Abstracting

Identifying the key words or terms needed to determine the accurate code

_______ confirm(s) medical necessity by pairing at least one diagnosis code to at least one procedure code

Linking

The most important source for details required for the coding specialist t determine the most accurate code or codes is found in which part of the patient's record?

Physician's Notes / Operative reports

What is the best way to begin abstracting clinical documentation?

Read all the way through the clinical documentation for the specific encounter

Section III

Reporting additional diagnoses

Etiology / manifestation convention ("code first", "use additional code" and "in diseases classified elsewhere" notes)

Section 1. A. 13

Format and Structure

Section 1. A. 2

Placeholder character

Section 1. A. 4

Abbreviations - Tabular List Abbreviations

Section 1. A. 6. b

Signs and symptoms

Section 1. B. 4

Conditions that are an integral part of a disease process

Section 1. B. 5

Conditions that are not an integral part of a disease process

Section 1. B. 6

Which is the official guideline is concerned with conditions that are an intergral part of a disease process?

Section 1.B.5

Section II

Selection of principal diagnosis

Services

Spending time with a patient and/or family about health care situations

Medical Necessity

The determination that the health care professional was acting according to standard practices in providing a particular procedure for an individual with a particular diagnosis

External Causes

The explanation of how a patient became injured or poisoned, as well as other necessary details about the event; a health concern caused by something outside of the body

Demographic

The patient's name, address, date of birth, and other personal details, not specifically related to health

Reimbursement

The process of paying for health care services after they have been provided

Alphabetic Index

The section of a code book showing codes, from A to Z, by the short code descriptions

Main section

The section of the CPT code book listing all of the codes in numeric order

Tabular List

The section of the ICD-10-CM code book listing all of the codes in alphanumeric order

Tables

The section of the ICD-10-PCS code book listing all of the codes in alphanumeric order, based on the first three characters of the code.

Coding process

The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between health care professional and patient.

Condition

The state of abnormality or dysfunction

Query

To ask; an official request to the attending physician for more specific information related to a patient's condition or treatment

Which of the following would be an example of an external causes code?

Y92.838

Diagnostic descriptions are listed by

conditions such as fractures, eponyms such as Epstein-Barr syndrome

Action 5 in the coding process is to

confirm medical neccesity

External causes explain ________ and _______ the patient became injured.

how, where

The patient has been diagnosed with hypersecretion of thyroid stimulating hormone. Identify the condition.

hypersecretion

The Index to External Cause lists the causes of

injuries and poisoning

Converting a meaning from one language into another is called

interpreting

Coding is accurately interpreting health care terms and definitions into _________ that specifically convey diagnosis and procedures

numbers or number-letter combinations

The ______ will have a coder to report for any imaging procedures

radiologist

A manifestation is a ______ condition caused by the ______ condition.

second, first

If you see this symbol + in the CPT code book's main section beside a code, it tells you that

the code is and add-on code

What is the correct ICD-10-PCS code for the Repair of the maxilla, left side, open approach?

0NQR0ZZ

Abstract the documentation is Action ________ in the coding process

1

There are _______ specific actions that you should take to construct your proper coding process

6

Inpatient

A patient admitted into a hospital for an overnight stay or longer

After abstracting the main terms, a coder will go next to the

Alphabetic Index

Which of the following code books lists the codes in numeric order?

CPT

An example of an ICD-10-CM code is

H61.022

______ codes are composed of seven characters

ICD-10-PCS

Sequela (Late Effects)

Section 1. B. 10

Laterality

Section 1. B. 13

Official ________ are a listing of rules and regulations instructing you how to use a specific code set is accurately.

guidelines

The Main Section and Tabular List of the code books all contain additional ______ and ______ to help you determine the most accurate code

symbols, notations