Chapter 2 - Abstracting Clinical Documentation

Question 1

Assume

Answer 1

• Supposed to be the case, without proof; guess the intended details.
• making up details, filling in the blanks with your own specifics, guessing, we’re substituting your own knowledge for missing facts.

Question 2

Symptoms

Answer 2

A patient’s subjective description of feeling.

Question 3

Query

Answer 3

To ask; an official request to the attending physicians for more specific information related to a patient’s condition or treatment.

• missing or incomplete
• Inconsistent or Ambiguous
• Contradictory

☆ Create a query using nonleading questions, with open-ended or multiple-option formatting:

▪Use an Open-ended query:
“ Which metatarsal bone was fractured?”

▪Use a Multiple-choice query:
" Which metatarsal bone was fractured?"
      A. First
      B. Second 
      C. Third
      D. Fourth
      E. Fifth

Question 4

Signs

Answer 4

Measurable indicators of a patient’s health status.

Question 5

Demographic

Answer 5

The patient’s name, address, date of birth, and other personal details, not specifically related to health.

Question 6

Interpret

Answer 6

• Explain the meaning of convert a meaning from one language to another.
• an exact science; it involves changing information from one language to another.

Question 7

Sequela

Answer 7

A cause and effect relationship between an original condition that has been resolved with a current condition; also known as a “late effect”.

• Requires at least two codes, in the following order:

  1. Sequela condition, which is the condition that resulted and is being treated, such as a scar or paralysis.
  2. Sequela (late effect) or original condition codes with the 7th character "S".

Question 8

Manifestation

Answer 8

A condition that develops as a result of another, underlying conditions.

Question 9

Abstracting

Answer 9

Identifying the key words or terms needed to determine the accurate code.

Question 10

Co-morbidity

Answer 10

A separate condition or illness present in the same patient at the same time as another, unrelated condition or illness.

Question 11

The first question you, as a professional coder, will need to ask is

Answer 11

For whom are you reporting?

Question 12

The ___________ will have a coder to report for any Imaging procedures.

Answer 12

Radiologist

Question 13

An Acute Care Facility

Answer 13

A hospital

Question 14

Interpreting

Answer 14

Converting a meaning from one language to another

Question 15

The most important source for details required for the coding specialist to determine the most accurate code or codes is found in which part of the patient record?

Answer 15

Physician’s Notes / Operative Reports

Question 16

What is the best way to begin abstracting clinical documentation?

Answer 16

Read all the way through the clinical documentation for specific encounter.

Question 17

Every patient encounter must have at least ___________ reportable (codeable) reason why and at least _________ reportable (codeable) explanation of what.

Answer 17

1, 1

Question 18

The following would be considered a diagnostic “main term”.

Answer 18

• infarction
• spasm
• herpes

Question 19

The patient has been diagnosed with hypersecretion of thyroid stimulating hormone. The condition is

Answer 19

Hypersecretion

Question 20

The official guideline that is concerned with conditions that are an integral part of a disease process

Answer 20

Section 1.B.5

Question 21

A manifestation is a _________ condition caused by the __________ condition.

Answer 21

Second, first

Question 22

Coding a sequela requires at least _______ codes.

Answer 22

2

Question 23

External causes explain _________ and ________ the patient became injured.

Answer 23

How, where

Question 24

The following would be an example of an external causes code.

Answer 24

Y92.838

Question 25

The suffix -plasty means

Answer 25

To repair.

Question 26

The abbreviation ECG stands for

Answer 26

Electrocardiography.

Question 27

What should you do when you find missing or incomplete information in the physician’s notes?

Answer 27

Query the Physician.

Question 28

What should you do before using an unspecified or NOS (not otherwise specified) code(s)?

Answer 28

Query The Physician to gain the details needed to use a more specific code.

Question 29

Watchwords

The Professional Coding Specialists’ Motto:

Answer 29

“If it isn’t documented, it didn’t happen. If it didn’t happen, you can’t code it!”

Question 30

Documentation

Answer 30

Means writing it down

Question 31

Coding bite Accuracy

Answer 31

Keep a medical dictionary by your side so that the minute you come upon a word you don’t understand for an absolute fact, you can look at it up right away. If you don’t understand what you are reading, you will not be able to interpret it accurately.

Question 32

For whom are you reporting?

Patient

Answer 32

Who is provided with care

Question 33

For whom are you reporting?

Physician

Answer 33

Who is the health care provider you are representing

Question 34

For whom are you reporting?

Diagnosis

Answer 34

Why the provider is caring for this individual during this encounter

Question 35

For whom are you reporting?

External cause

Answer 35

How and where the patient became injured

Question 36

For whom are you reporting?

Procedure

Answer 36

What the provider did for the individual

Question 37

For whom are you reporting?

Facility

Answer 37

Where the services were provided

Question 38

In an outpatient encounter, if there is no cofirmed diagnostic statement, you will code the patient’s __________ and/or ____________that led to the physician’s decision for the next step in care.

Answer 38

Signs and symptoms

Question 39

When an inpatient (admitted into the hospital) is being discharged without a confirm diagnosis, you will code the suspected _________ listed on the discharge summary as if they were confirmed.

Answer 39

Condition

You will not code the signs and symptoms.

Question 40

ICD-10-CM General coding guidelines in chapter specific guidelines:

Answer 40

• B.4 signs and symptoms
• B.5 conditions that are an integral part of a disease process
• B.6 conditions that are not an integral part of a disease process