Chapter 2 - Abstracting Clinical Documentation Flashcards
Terminology
Assume
- 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.
Symptoms
A patient’s subjective description of feeling.
Query
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
Signs
Measurable indicators of a patient’s health status.
Demographic
The patient’s name, address, date of birth, and other personal details, not specifically related to health.
Interpret
- Explain the meaning of convert a meaning from one language to another.
- an exact science; it involves changing information from one language to another.
Sequela
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".
Manifestation
A condition that develops as a result of another, underlying conditions.
Abstracting
Identifying the key words or terms needed to determine the accurate code.
Co-morbidity
A separate condition or illness present in the same patient at the same time as another, unrelated condition or illness.
The first question you, as a professional coder, will need to ask is
For whom are you reporting?
The ___________ will have a coder to report for any Imaging procedures.
Radiologist
An Acute Care Facility
A hospital
Interpreting
Converting a meaning from one language to another
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?
Physician’s Notes / Operative Reports
What is the best way to begin abstracting clinical documentation?
Read all the way through the clinical documentation for specific encounter.
Every patient encounter must have at least ___________ reportable (codeable) reason why and at least _________ reportable (codeable) explanation of what.
1, 1
The following would be considered a diagnostic “main term”.
- infarction
- spasm
- herpes
The patient has been diagnosed with hypersecretion of thyroid stimulating hormone. The condition is
Hypersecretion
The official guideline that is concerned with conditions that are an integral part of a disease process
Section 1.B.5
A manifestation is a _________ condition caused by the __________ condition.
Second, first
Coding a sequela requires at least _______ codes.
2
External causes explain _________ and ________ the patient became injured.
How, where
The following would be an example of an external causes code.
Y92.838
The suffix -plasty means
To repair.
The abbreviation ECG stands for
Electrocardiography.
What should you do when you find missing or incomplete information in the physician’s notes?
Query the Physician.
What should you do before using an unspecified or NOS (not otherwise specified) code(s)?
Query The Physician to gain the details needed to use a more specific code.
Watchwords
The Professional Coding Specialists’ Motto:
“If it isn’t documented, it didn’t happen. If it didn’t happen, you can’t code it!”
Documentation
Means writing it down
Coding bite Accuracy
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.
For whom are you reporting?
Patient
Who is provided with care
For whom are you reporting?
Physician
Who is the health care provider you are representing
For whom are you reporting?
Diagnosis
Why the provider is caring for this individual during this encounter
For whom are you reporting?
External cause
How and where the patient became injured
For whom are you reporting?
Procedure
What the provider did for the individual
For whom are you reporting?
Facility
Where the services were provided
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.
Signs and symptoms
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.
Condition
You will not code the signs and symptoms.
ICD-10-CM General coding guidelines in chapter specific guidelines:
- 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
