Ch 12: Review Test Flashcards
Diagnostic Coding
A recognized process of transforming descriptions of a patient’s disease process, disorder, or injury into universal numerical or alphanumerical formats is referred to as what?
Coding
The reason (sore throat or chest pain) that brings a patient to the healthcare facility is commonly referred to as a(n) ____?
Diagnosis
In what year was the first ICD system (ICD-1) put into use?
1900
Diagnosis codes in the outdated ICD-9-CM system consisted of ____ digits or characters?
3 to 5
Diagnosis codes in the ICD-10-CM system consist of how many digits or characters?
3 to 7
The Alphabetic Index in ICD-10 lists all diagnostic terms in what order?
Alphabetic order
Part III (Tabular List of Diseases and Injuries) of the ICD-10-CM coding manual is composed of ____ chapters?
21
What are three common uses of coding?
- Setting health policy
- Monitoring resource utilization
- Preventing healthcare fraud and abuse
What are three valid reasons for converting to ICD-10-CM?
- Lack of specificity in ICD-9 codes
- Lack of available code numbers in ICD-9
- ICD-10-CM uses full code titles, reflecting advances in medical technology
In the current diagnostic coding system, what is the manual used for coding inpatient procedures?
ICD-10-PCS
Where are diagnosis codes in ICD-10-CM used?
- All physicians’ offices
- Outpatient clinics
In fracture care, a seventh character A indicates what?
An initial encounter
After the diagnosis has been determined, the ____ in the diagnosis should be identified
Main term or Lead term
When diseases, procedures, or syndromes are named after the individual who discovered or first used them, they are commonly referred to as what?
Eponyms
What is the main term in the diagnosis of premature atrial contraction (PAC)?
Premature
Some categories, mainly those subject to notes linking them with other categories, require multiple indexing steps. To avoid repeating multiple steps for each of the additional terms involved, a ____ is used.
Cross-reference
After the provisional code is located in the ____, the coder should verify the code by locating it in the ____ to ensure that the diagnosis has been coded to the optimal specificity
Alphabetic Index / Tabular List
Codes are arranged in the Tabular and divided into chapters based on ____
- Anatomical site
- Body system
- Etiology
In ICD-10 diagnostic codes, the letter “x” means what?
- Allows for future expansion of the code
- Is used to fill out empty characters when a code contains fewer than six characters and a seventh character applies
How is the Index to Diseases in the ICD-10-CM coding manual organized?
Alphabetically by main terms
What do essential modifiers describe?
- Various anatomical sites
- The cause or origin of a disease or condition
- Clinical types
Terms enclosed in parentheses after main terms are called what?
Nonessential modifiers
If a patient’s condition has not been specifically diagnosed, the health insurance professional must code what?
Signs or symptoms
The ____ code represents the condition that is most commonly associated with the main term or is the unspecified code for the condition
Default
What is the main term for “acute depressive reaction”?
Reaction
When a term has many modifiers that might be listed beneath more than one term; what cross-reference is used?
See also
In most ICD-10-CM manuals, main terms in the index appear in ____?
Bold type
What is the “placeholder character” in ICD-10-CM?
The letter “x”
In ICD, rules and guidelines used in coding are commonly referred to as what?
Conventions
Identify the symbol that typically is used in the Tabular List when an addition digit (or digits) is needed to code a diagnosis to its greatest specificity
Bullet
NEC in the ICD-10-CM system represents what?
Not elsewhere classified
In ICD-10, when a code appears with a Type 1 Excludes note, it means what?
Not coded here
In medicine, ____ is a sign or symptom of a disease
A manifestation
A ____ code is a single code used to classify two diagnosis with an associated secondary process (manifestation)
Combination
In medicine, the study of the form and structure of organisms and their specific structural features is called ____?
Morphology
A code listed next to a main term in the ICD-10-CM Index is referred to as a ____?
Default code
Sequelae are the ____ or injury or illness
Late effects
Which character in an ICD-10-CM code indicates laterality for bilateral sites?
The last character in a six-character code
The coder should always begin the search for the correct code assignment in the ____?
Alphabetic Index
Under HIPAA, a ____ is any set of codes used for encoding data elements, such as tables of terms, medical concepts, or medical diagnosis codes
Code set
What must be coded if a patient’s condition has not been specifically diagnosed?
Signs or symptoms
How should you code a patient that has both scarlet fever and strep throat?
Two separate codes must be used
Identify what must be coded first if a patient’s diagnosis is “diabetic ulcer of the heel”
Diabetes
