Ch 1: Textbook Questions Flashcards
The Rationale for and History of Coding
What does a coder do?
Medical coding consists of translating diagnosis and procedures into special alphanumeric characters for the purpose of statistically capturing it.
What coding system is currently used in the United States for diagnosis coding?
ICD-10-CM
What does the CM of ICD-10-CM stand for?
Clinical Modification
List three uses for coded data.
- Research
- Reimbursement
- Quality Improvement
- Risk Management
- Clinical Pathways
- Planning
Describe the difference between a nomenclature and a classification system.
A nomenclature is a system of names or preferred terminology, and a classification system is a grouping of like items for storage
What nomenclature of disease is used in the United States?
Systematized Nomenclature of Medicine (SNOMED)
Define a closed classification system.
An item may be classified in only one place
When was the International Classification of Diseases first adopted by the United States?
1898
When and how often is ICD-10-CM updated?
Biannually in October and April
What four groups constitute the Cooperating Parties?
- National Center for Health Statistics (NCHS)
- CMS
- American Hospital Association (AHA)
- American Health Information Management Association (AHIMA)
Who publishes official coding advice and guidance?
American Hospital Association (AHA)
What organizations award coding credentials?
- American Health Information Management Association (AHIMA)
- American Academy of Professional Coders (AAPC)
What is another word that is used in the industry for “following the rules”?
Compliance
If you were coding a neighbor’s record, would it be okay for you to tell your other neighbors the reason the patient was hospitalized?
No
What does HIPAA stand for?
Health Insurance Portability and Accountability Act of 1966
