Chapter 3: The Coding Process

Abstract the documentation is Action _____ in the coding process.

1

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

1,1

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

43653

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

6

The most important factor in coding is

Accuracy of Codes

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

Alphabetic Index

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

Alphabetic Index

A code consisting of both numbers and letters.

Alphanumeric

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

CPT

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.

Coding Process

Action 5 in the coding process is to

Confirm Medical Necessity

Which of the following is a full code description? Furuncle of trunk L02.22 Carbuncle of trunk L02.23 Cutaneous abscess of chest wall L02.213 Impetigo L01.0

Cutaneous abscess of chest wall L02.213

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

Guidelines

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

HCPCS Level II

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

ICD-10-CM

__________ codes are composed of seven characters.

ICD-10-PCS

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

Linking

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

Linking

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

Main Section

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

Notations

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

Official Guidelines

Conventions, general coding guidelines and chapter specific guidelines.

Section 1 of ICD-10-CM Official Guidelines

Selection of Principal Diagnosis.

Section 2 of ICD-10-CM Official Guidelines

Reporting Additional Diagnoses.

Section 3 of ICD-10-CM Official Guidelines

Diagnostic Coding and Reporting Guidelines for Outpatient Services.

Section 4 of ICD-10-CM Official Guidelines

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

Symbols

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

Symbols, Notations

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.

Tables

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

Tabular List

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

Use additional code to identify alcohol abuse and dependence

The why justifies the _____

What

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

front of the code book

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

the code is an add-on code.