Ch 4: Terms

Question 1

Admitting Diagnosis

Answer 1

The condition that requires the patient to be hospitalized

Question 2

Alphabetic Index

Answer 2

The index found in the ICD-10-CM book for both disease conditions and procedures

Question 3

Chief Complaint

Answer 3

The reason, in the patient’s own words, for presenting to the hospital

Question 4

Differential Diagnosis

Answer 4

When a symptom may represent a variety of diagnosis

Question 5

Discharge Summary

Answer 5

A review of the patient’s hospital course. This summary details the reason for admission or tests or procedures performed and how the patient responded

Question 6

Eponym

Answer 6

Term for a disease, structure, procedure, or syndrome that has been named for a person

Question 7

Main Term

Answer 7

Term that identifies disease conditions or injuries; it is identified in bold print and set flush with the left margin of each column in the Alphabetic Index

Question 8

Nonessential Modifier

Answer 8

Term that is enclosed in parentheses; its presence or absence does not affect code assignment

Question 9

Principal Diagnosis

Answer 9

Condition established after study to be chiefly responsible for occasioning admission of the patient to the hospital for care

Question 10

Subterm

Answer 10

Gives more specific information about a main term. Subterms identify site, type, or etiology of a disease condition or injury. Also, modifiers that are indented to the right of the main term.

Question 11

Tabular List

Answer 11

Section of the ICD-10-CM book that contains the code listing, along with exclusion or inclusion notes