CH 1-3 INTERMEDIATE MEDICAL CODING

Abstract the documentation is action ______in coding process

1

Every encounter between patient and health care professional must have at least _____diagnosis code and at least _______procedure code(s)

1,1

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

43653

The are _____specific actions that you should take to construct your proper coding process

6

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

ABSTRACT THE DOCUMENTATION

What is the most important factor to consider when coding?

ACCURACY

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

ACUTE

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

ALPHABETIC INDEX

THE SECTION OF A CODE BOOK SHOWING CODES, FROMA -Z BY THE SHORT CODE DESCRIPTIONS

ALPHABETIC INDEX

A seperate diagnosis existing in the same patient at the same time as an unrelated diagnosis is known as

CO-MORBIDITY

THE SEQUENCE OF ACTIONS REQUIRED TO INTERPRET PHYSICIAN DOCUMENTATION INTO THE CODES THAT ACCURATELY REPORT WHAT OCURRED DURING A SPECIFIC ENCOUNTER BETWEEN THE HEALTH CARE PROFESSIONAL AND PATIENT

CODING PROCESS

Action 5 in the coding process is to

CONFIRM MEDICAL NECESSITY

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

CPT

Which of the following is a full code description

CUTANEOUS ABSCESS OF CHEST WALL L02.213

A physicians determination of a patients condition, illness , or injury

DIAGNOSIS

Asthma is an example of a(n)

DIAGNOSIS

The abbreviation ECG stands for

ELECTROCARDIOGRAPHY

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 in the

FRONT OF THE CODE BOOK

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 in which Alphabetic index

HCPCS Level 2

External causes explain _______and______the patient became injured

HOW,WHERE

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

__________codes are composed of seven characters

ICD-10-PCS

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

INPATIENT

Converting a meaning from one language to another is called

INTERPRETING

__________confirms medical necessity by painting at least one diagnosis code to at least one procedure code

LINKING

THE SECTION OF THE CPT CODE NOOK LISTING ALL OF THE CODES IN NUMERIC ORDER

MAIN SECTION

HCPCS Level 2 Codes are presented as

ONE LETTER FOLLOWED BY FOUR NUMBERS

HCPCS Level 2 codes are presented as

ONE LETTER FOLLOWED BY FOUR NUMBERS

EXPLAINS WHO IS PROVIDED WITH CARE

PATIENT

This documentation r section that includes the patient's demographic information , as wellas health insurance policy numbers and the name of the individual who is responsible for the patients care

PATIENTS REGISTRATION FORM

Explains what the provider did for the individual

PROCEDURE

Surgical removal of a skin tag is an example of a

PROCEDURE

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

REPAIR

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

SERVICES

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

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 CM CODE BOOK LISTING ALL OF THE CODES IN THE ALPHANUMERIC ORDER

TABULAR LIST

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

THE CODING PROCESS

What is abstracting?

THE PROCESS IF IDENTIFYING THE KEY WORDS OR TERMS IN HEALTH CASE DOCUMENTATION IN ORDER TO DETERMINE THE BEST, MOST APPROPRIATE CODE

When ICD-10-CM codes support medical necessity this means that

THERE WAS A VALID MEDICAL REASON TO PROVIDE CARE 21WQ

Suffix: -ectomy means

TO REMOVE

The provision of medical care for a disorder or disease

Treatment

In the ICD 10 CM tabular list above code K70.31 there is a rotation. What is rotation?

USE ADDITIONAL CODE TO IDENTIFY ALCOHOL AND ABUSE AND DEPENDENCE

THE WHY JUSTIFIES THE

WHAT

A diagnosis explains

WHY THE PATIENT REQUIRES ATTENTION OF THE PROVIDER