Chapter 2 & Chapter 3 Skills Check

Explains how and where the patient became injured.

External Cause

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

Official Guidelines

When querying a provider, what is the best approach in asking the questions?

Open-ended or multiple choice

Results of testing performed on blood, tissue and other specimens hold important keys to the patient's condition. The results can provide you with important details necessary for you to determine a specific, accurate code. You can locate this information in the:

Pathology and Laboratory Reports

This document or section includes the patient's demographic information, as well as health insurance policy numbers and the name of the individual who will be financially responsible for the patient's care.

Patient's Registration Form

When should a coder query the physician?

When there is unclear or missing information necessary to code an encounter.

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

the coding process

Which code represents an ICD-10-PCS code?

07PK4CZ

What of the following CPT codes indicates the highest level of specificity available for an esophagogastroduodenoscopy, flexible, transoral, with directed placement of percutaneous gastrostomy tube?

43246 (CPT codes are required to have 5 characters)

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

Alphabetic Index

_________ is to suppose to be the case, without proof, guess the intended details.

Assume

The ______ will have a coder to report for any heart problems.

Cardiologist

Which of the following are pathways to query a provider?

Charts with query notes attached to the front of the chart, encrypted email system, and electronic health record software programs.

In the ICD-10-CM Tabular List below code G01 there is a notation. What is the notation?

Code first underlying diseases

The six actions of accurate coding include:

Coding only documented conditions

When a specialist is asked by an attending physician to evaluate a patient's condition, a report is written and sent over to be included in the patient's medical record in the requesting physician's files, as well as those belonging to the consulting physician. You can locate this information in the:

Consultations Reports

For coding purposes, why are diagnosis codes important?

Establish the case for medical necessity

According to the ICD-10-CM Official Guidelines, section ____ corresponds to Conventions, general coding guidelines and chapter specific guidelines.

I

According to the ICD-10-CM Official Guidelines, section _____ corresponds to Selection of Principal Diagnosis guidelines.

II

According to the ICD-10-CM Official Guidelines, section _______ corresponds to Diagnostic Coding and Reporting Guidelines for Outpatient Services guidelines.

IV

Where are the ICD-10-CM Official Guidelines for Coding and Reporting published?

In front of the ICD-10-CM Manual

Explains what the provider did for the individual

Procedure

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

Query

What is the main term in the following procedural statement? Repair of an abdominal hernia.

Repair

Which of the following ICD-10-CM codes indicates the highest level of specificity available for a dislocation of a sacroiliac and sacrococcygeal joint, initial encounter?

S33.2xxA

Refer to the ICD-10-CM Official Guidelines Section I.C.1.d. This guideline concerns

Sepsis, severe sepsis and septic shock

Measurable indicators of a patient's health status is know as a?

Sign

Which of the following would be an example of an external cause code

X17.xxxA

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

Symbols

What is abstracting?

The process of identifying the key words or terms in health care documentation in order to determine the best, most appropriate code.

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

Y35.001A

The written plan of care should include which of the following?

Treatments and medications, specifying frequency and dosage

In the ICD-10-CM Tabular List above code E00.0 there is a notation. What is the notation?

Use additional Code (F70-F79) to identify associated intellectual disabilities

There are six specific actions that you should take as part of the coding process. What is action 1?

abstract the documentation

The _______ will have a coder to report for any administration of anesthesia.

anesthesiologist

Alphanumeric content contains

both letters and numbers

In CPTs Alphabetic Index you will see all of the following except

commode

Asthma is an example of a(n)

diagnosis

Thrombolysis means

dissolve dangerous cloths in blood vessels

In an inpatient setting, the diagnosis code reported must support the _____ for the patient to require acute care in a hospital setting.

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 is known as

medical necessity

In diagnostic coding NOS stands for

not otherwise specified

If you see use additional code in the Tabular List, this is known as a/an

notation

Refer to the ICD-10-CM Official Guidelines Section IV.K. This guideline concerns

patient's receiving diagnosis services only

There are 6 specific actions that you should take as part of the coding process. What is action 2?

query

A cause-and-effect relationship between an original condition that has been resolved with a current condition is known as a _______.

sequela

-ectomy means

surgical removal

A patient's subjective description of feeling is known as a

symptom

The star symbol next to a CPT code indicates?

that the code may be used to report telemedicine services when modifier 59 is appended

Refer to the ICD-10-CM Official Guidelines Section II.C. This guideline concerns

two or more diagnoses that equally meet the definition for principal diagnosis