Chapter 1-3 Review: 0ST-248
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
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
Every patient encounter must have at least _____ reportable [codeable] reason why and at least _____ reportable [codebale] explanation of what.
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
There are _______ specific actions that you should take to construct your proper coding process
6
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
Inpatient
A patient admitted into a hospital for an overnight stay or longer
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
After abstracting the main terms, a coder will go next to the
Alphabetic Index
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
Which of the following code books lists the codes in numeric order?
CPT
Linking
Confirming medical necessity by pairing at least one diagnosis code to at least one procedure code.
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
Section IV
Diagnostic Coding and Reporting Guidelines for Outpatient Services
Interpret
Explain the meaning of; convert a meaning from one language to another
An example of an ICD-10-CM code is
H61.022
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
______ codes are composed of seven characters
ICD-10-PCS
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
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
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
"Code Also" note
Section 1. A. 17
Format and Structure
Section 1. A. 2
Placeholder character
Section 1. A. 4
Abbreviations - Tabular List Abbreviations
Section 1. A. 6. b
Sequela (Late Effects)
Section 1. B. 10
Laterality
Section 1. B. 13
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
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
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
Treatment
The provision of medical care for a disorder or disease
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
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
Which of the following would be an example of an external causes code?
Y92.838
The most important factor in coding is
accuracy of codes
All of the following would be considered a diagnostic "main term" except
acute
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
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
Official ________ are a listing of rules and regulations instructing you how to use a specific code set is accurately.
guidelines
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
The Main Section and Tabular List of the code books all contain additional ______ and ______ to help you determine the most accurate code
symbols, notations
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
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