Chapter 3 & 4

Question 1

Coding Process

Answer 1

the sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between health care professional and patient

Question 2

Alphabetic Index

Answer 2

the section of a code book showing all codes from A-Z by the short code descriptions

Question 3

Symbols

Answer 3

marks, similar to emojis that provide additional direction to use codes correctly and accurately

Question 4

Notations

Answer 4

alerts and warnings that support more accurate use of codes in specific code set

Question 5

Tabular List of Disease and Injuries

Answer 5

the section of the ICD-10-CM code book listing all of the codes in alphanumeric order

Question 6

Main Section

Answer 6

the section of the CPT code book listing all of the codes in numeric order

Question 7

Tables

Answer 7

the section of the ICD-10-PCS codebook listing all of the codes in alphanumeric order,based on the first three character of code

Question 8

Alphanumeric Section

Answer 8

the section of the HCPCS Level II code book listing all of the codes in alphanumeric order

Question 9

Alphanumeric

Answer 9

containing both letters and numbers

ICD-10-Tabular List

Question 10

Official Guidelines

Answer 10

a listing of rules and regulations instructing how to use a specific code set accurately

Question 11

Linking

Answer 11

confirming medical necessity by pairing at lease one diagnosis code to at least one procedure code

Question 12

List the 6 Coding Actions in Order

Answer 12

1. Abstract Documentation
2. Query if Necessary
3. Code the diagnosis or diagnoses
4. Code the procedure or procedures
5. Confirm medical necessity
6. Double check your codes

Question 13

Action 1 in the Coding Process

Answer 13

Abstract Documentation

read carefully through
re read the docs and identify the main terms the diagnosis (WHY) & procedures (WHAT) of the encounter

Question 14

Action 2 in the Coding Process

Answer 14

Query if Necessary

never assume or guess if something is unclear, missing, contradictory

Question 15

Action 3 in the Coding Process

Answer 15

Code the diagnosis or diagnoses & signs or symptoms describing why the health care professional treated this patient during encounter

use best most accurate code or codes available based on documentation

Question 16

Action 4 in the Coding Process

Answer 16

Code the procedure or procedures

-Determine whom / Describing What

physician or out patient facility =CPT
hospital or inpatient facility = ICD-10-CM-PCS
HCPCS Level II= transportation, equiptment, durgs

Question 17

Action 5 in the Coding Process

Answer 17

Confirm medical necessity

each procedure code matches/is supported by at least one diagnosis code to verify medical necessity

Question 18

Action 6 in the Coding Process

Answer 18

Double check your codes

slowly, carefully, completely

Question 19

What does it mean when you see X

Answer 19

a place holder / holds a spot for futre expansion of the diagnosis

may need up to 3 X placeholders

X may not be at the end of a code

ex- S61.250X

Question 20

Systemic Condition

Answer 20

a condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision making for any other condition

Question 21

Principal Diagnosis

Answer 21

the condition after study that is the primary or main reason for the admission of a patient to the hospital for fare the condition that requires the largest amount of hospital resources fore care

Question 22

First Listed

Answer 22

“first-listed” diagnosis is used when reporting outpatient encounters, instead of the term “principal diagnosis”

Question 23

acute

Answer 23

sever, serious

Question 24

chronic

Answer 24

long duration continuing over an extended period of time

Question 25

unspecified

Answer 25

the absence of additional specifics in the physicians documentation

Question 26

anatomical site

Answer 26

a specific location within the anatomy (body)

Question 27

confirmed

Answer 27

found to be true or definite

Question 28

other specified

Answer 28

additional information the physician specified that isn’t included in any other code description

Question 29

underlying condition

Answer 29

one disease that affects or encourages another condition

Question 30

differential diagnosis

Answer 30

when the physician indicates that the patients signs and symptoms may closely lead to two different diagnoses usually written as diagnosis A vs diagnosis B

Question 31

NEC - not elsewhere classified

Answer 31

used when ICD-10-CM does not provide a specific code for a patients condition

the provider documented more specific info regarding the patients condition but there isn’t a code in ICD-10-Cm that reports the code accurately

Question 32

NOS- not otherwise specified

Answer 32

equivalent to unspecified and is used only when info lacks the information necessary to report a more specific code (might query Dr for more info in this situation)

Question 33

Brackets (2 meanings)

Answer 33

used in Tabular List to enclose synonyms alternate wording, or explanatory phrases

used in alphabetic index to indicate multiple codes are required

Question 34

Parenthesis

Answer 34

used to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code # to which is assigned the terms in the parenthesis are known as Non Essential Modifiers

Question 35

Bold Face Type

Answer 35

used for all codes and titles in the tabular list and for the main terms in the alphabetical index

Question 36

Excludes 1

Answer 36

represents that the condition is NOT coded here. this note indicates that the code excluded should NOT be used at the same time as the code about the excludes 1 note, IF THE CONDITIONS ARE RELATED. They indicate when 2 conditions should NOT be reported together

ex a congenital form vs an aquired form of the same condition

in some cases the 2 codes may be used together when the conditions are unrelated to each other

Question 37

Excludes 2

Answer 37

represents that the condition is NOT included here. indicates that the condition excluded is not part of the represented by the code, but a patient may have both conditions at the same time. when a type 2 excludes note appears under a code, it is acceptable to sue both the code and the excludes code together

Question 38

Includes

Answer 38

appears immediately after a three character code title to further define or clarify the category

Question 39

List Etiology/ Manifestation Codes (4)

Answer 39

1. uses additional codes
2. uses additional code if applicable
3. code 1st
4. combination code

Question 40

uses additional code

Answer 40

signals the coder that an additional code should be used if the info is available to provide a more complete picture of the diagnosis

Question 41

use additional code if applicable

Answer 41

causal condition note indicates that this code may be assigned as the principle diagnosis if the cause is not known, however if the causal condition is know it should be sequenced 1st

Question 42

Code 1st

Answer 42

used in categories not intended to be the principal diagnosis. requires that the underlying disease be sequenced 1st and its manifestation 2nd

Question 43

Combination Code

Answer 43

single code is used to classify 2 diagnoses a primary diagnosis with an associated secondary diagnosis or with an associated complication

Question 44

Italicized or Slanted Brackets

Answer 44

found in the alphabetical index and will surround additional code or codes

ex- secondary codes that must be included with initial code