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Z. CDAB 1 > Chapters 1 - 4 > Flashcards

Chapters 1 - 4 Flashcards

1
Q

What does CIHI do?

A

develop databases, HI standards, identify national health indicators, distribute HI

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2
Q

What is DAD?

A

Discharge Abstract Database

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3
Q

What is CIHI?

A

Canadian Institute for Health Information

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4
Q

What is an abstract?

A

The input document in a software system where all coding information is entered.

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5
Q

All DAD entries and corrections in Alberta are submitted to:

A

Alberta Health and Wellness

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6
Q

Once health information is reviewed by AH&W, where is it sent to?

A

CIHI

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7
Q

What are the 2 patient servicing services applied to patients?

A
  1. Main Patient Service (decided by HIM professional)2. Physician Service
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8
Q

T or F: Main Patient Service and Physician Service must fall under the same specialty.

A

False. They may be entirely different, especially in small hospitals where not all services are staffed. Physician specialty isn’t a factor when assigning the main patient service.

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9
Q

What is a Main Patient Service?

A

Service MOST RESPONSIBLE for pt care during stay.

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10
Q

What must a patient’s age range be to fall under a paediatric patient service?

A

12 years and under

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11
Q

When is the Newborn General Service assigned?

A

An infant is only classified under this service in the facility they were BORN IN.

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12
Q

T or F: No chart is created for a stillbirth.

A

True. No abstract is created by admitting a stillborn; we create the abstract separately to enter data. Mother’s chart would be an Obstetrics Delivered service.

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13
Q

What is the difference between medical and surgical services?

A

No surgery performed for medical services. Surgical interventions performed for surgical services. *Surgical services are assigned if the attending is a surgeon even if no surgery was performed.

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14
Q

When is Obs Antepartum assigned?

A

Mother treated for a PREGNANCY-RELATED CONDITION but discharged BEFORE DELIVERY.

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15
Q

When is Obs Postpartum assigned?

A

During the 42 DAY puerperal or post-delivery period

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16
Q

T or F: Ectopic pregnancies are assigned to Obs Aborted.

A

False. Ectopic pregnancies are service to gynecology.

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17
Q

T or F: treatment using sutures is serviced to plastic surgery.

A

True.

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18
Q

T or F: You would service upper respiratory problems to respirology.

A

False. Upper respiratory issues are serviced to OTOLARYNGOLOGY while lower lung issues are serviced to RESPIROLOGY.

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19
Q

What is the main purpose of coding?

A

Coding: translating MEDICAL TERMINOLOGY into a CLASSIFICATION SYSTEM that can be easily manipulated for STATISTICAL ANALYSIS and reporting

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20
Q

What are the two components of coding?

A
  1. INTERPRETATION of the SOURCE DOCUMENTS (pt chart)2. CODE ASSIGNMENT
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21
Q

What is the difference between ICD-10 and ICD-10-CA?

A

ICD-10-CA is a Canadian modification of ICD-10. While ICD-10 was developed by the WHO, ICD-10-CA was modified for Canadian use by CIHI. It includes issues that are exclusive or relevant to Canadians, such as injuries caused by skates, skis, and ice.

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22
Q

What is CCI?

A

CCI stands for Canadian Classification of Health Interventions. They contain codes for INTERVENTIONS such as diagnostic or therapeutic procedures.

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23
Q

T or F: CCI was developed by the World Health Organization.

A

False. CCI was developed by CIHI.

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24
Q

What are examples of source documents?

A

Inpatient records, operative reports, emergency reports, ambulatory care reports (bloodwork, xrays, CT, MRIs)

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25
Q

What are 3 factors that influence the interpretation of source documents?

A
  1. Physician DOCUMENTATION STYLE (penmanship)2. COMPLETION or INCOMPLETION of record at time of coding3. Coder KNOWLEDGE and EXPERIENCE
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26
Q

What is involved in code assignment?

A

Code assignment involves choosing and assigning ALPHANUMERIC CODES from ICD and CCI to represent disease and intervention data.

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27
Q

What do we call the use of health data for statistical and reporting purposes?

A

This is called SECONDARY USE or HEALTH SYSTEM USE (HSU), the goal of which is to improve the health of Canadians and the health care system. This use can determine incidence of disease, resource allocation, opportunities for growth in providing quality of care, education and research.

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28
Q

What is the main purpose of ICD-10?

A

It is the international classification system for classifying mortality and morbidity data.

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29
Q

What is a classification?

A

A systemic method of arranging elements based on a particular point of view. ex. Physicians look at health care problems from the POV of medical diagnoses. Nurses look at conditions in relation to specific care needs.

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30
Q

T or F: ICD-10-CA can be based on your point of view.

A

False. ICD-10-CA is based on the PHYSICIAN POV. i.e. diseases and health related problems as described in a diagnoses.

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31
Q

T or F: Diseases and health-related problems are collectively called CONDITIONS.

A

True.

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32
Q

T or F: ICD-10-CA isn’t confined to one category.

A

False. ICD-10-CA is confined to a limited number of MUTUALLY EXCLUSIVE categories. It provides for ONE and ONLY ONE category for each and every possible condition.

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33
Q

What is the difference between statistical classification and a nomenclature/terminology list?

A

Statistical classification follows the concept of grouping related conditions. A nomenclature/terminology list gives a separate category for each condition and each term used to describe them.

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34
Q

What are the 3 categories in ICD-10-CA?

A
  1. SPECIFIC – common diseases2. LESS SPECIFIC – groups of separate but related conditions3. RESIDUAL – less specific, less common, misc conditions. Would be under headings such as “Other congenital malformations of larynx”
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35
Q

What is an axis and what type of axis is involved in ICD-10-CA?

A

Axis is the CRITERION for which classification is based. ICD-10-CA is a VARIABLE AXIS classification. Ex. axis: local diseases by site (respiratory system). condition: allergic asthma

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36
Q

What are the 2 major structural components in ICD-10-CA?

A
  1. Tabular list2. Alphabetical Index
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37
Q

What is the tabular list?

A

This is the classification itself and where the codes reside. Consists of a NUMERIC LISTING in ALPHANUMERIC ORDER of diagnosis codes, injury codes, etc.

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38
Q

How is the tabular list organized?

A

It is organized into CHAPTERS (blue), BLOCKS (black), and CATEGORIES (red text).

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39
Q

T or F: There are 25 chapters in the tabular list.

A

False. There are 23 chapters that correspond to the primary axes of the classification.

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40
Q

Which group of chapters is referred to as the body system chapters?

A

Chapters 6-14: Local diseases arranged by site

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41
Q

What are the rest of the chapter groups referred to?

A

Special group chapters.

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42
Q

T or F: When in doubt as to whether a condition is classified to a body system chapter or special group chapter, the special group chapter takes prirority.

A

True.

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43
Q

The first letter in an ICD10CA code is stands for______.

A

The chapter. Small chapters share letters, like D (II and III) and H (VII and VIII). Others are so large they require more than one letter.

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44
Q

T or F: U is reserved for temporary placement of newly created categories until a permanent placement is determined.

A

True.

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45
Q

Why is the beginning of each chapter important?

A

The beginning of each chapter provides instructions. Ex. When a condition is classifiable to a special group chapter, it takes precedence over assignment to a body system ch.

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46
Q

What are blocks?

A

Chapters are subdivided into blocks of THREE CHARACTER CATEGORIES. Blocks GROUP one or more adjacent categories into a related group of conditions. Ex. D50-D53 Nutritional anemias.

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47
Q

T or F: You must review instructions at the beginning of a chapter, block and three letter category before confirming your code selection.

A

True.

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48
Q

What are three character categories?

A

The code. An alphabetic character followed by two numeric characters.

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49
Q

What are residual categories?

A

OTHER and UNSPECIFIED categories. Ex. N32 other disorders of bladder

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50
Q

T or F: Most 3 character categories are further subdivided into 4 character categories.

A

True.

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51
Q

T or F: The fourth character is optional.

A

False. It is mandatory; the 3 chars can’t stand alone. When a category has been further subdivided, assign all available characters.

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52
Q

What does the “.—” (point dash) symbol mean?

A

It indicates an INCOMPLETE ICD CODE.

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53
Q

T or F. When the three character category isn’t subdivided, it stands alone.

A

True. Ex. N40 Hyperplasia of prostate

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54
Q

What is a four character subcategory?

A

Used to provide more detailed info within a three character category. This fourth character may represent different sites or extent of condition. Ex. K35 Acute appendicitis.

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55
Q

T or F: 3 character categories describe individual diseases within a group while 4 represents a group of conditions.

A

F. 3= group of conditions. 4 = individual diseases within that group.

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56
Q

What are .8 and .9 fourth character codes generally used for?

A

Fourth char .8 is used for OTHER conditions within the thee char category while .9 represents UNSPECIFIED ones. These are called residual subcategories. N64.8 Other specified disorders of breastN64.9 Unspecified disorders of breast

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57
Q

What are five- and six- character subcategories?

A

These provide SUBCLASSIFICATIONS to represent ADDITIONAL AXES. Ex. Anatomical site or episode of caste

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58
Q

What is the alphabetical index?

A

An alphabetical listing of diseases, injuries, factors influencing health status or other reasons for contact with the health care system. It is a list of DIAGNOSTIC TERMS found in health care documentation.

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59
Q

T or F: The tabular list leads to the alphabetical index.

A

F. The alphabetical index leads to the codes in the tabular list.

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60
Q

T or F: Alphabetical Index must be referenced first befit the Tabular List.

A

T.

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61
Q

The alphabetical index consists of what 3 sections?

A
  1. Alphabetical Index to Diseases and Nature of Injuries — Index to codes in ALL chapters int he tabular list (binocular 1)2. External Causes of Injury — most codes in the tabular list in CH 20 (bin 2)3. Table of Drugs and Chemicals — index to remaining codes in CH 19 and 20 relating to drugs and chemicals (bin 3)
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62
Q

How is the alphabetical index organized?

A

It is organized by LEAD TERMS with SECONDARY TERMS indented below.

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63
Q

What are lead terms?

A

Lead terms indicate the NOUN expressed as the name of a disease, injury, factor influencing health status or reason for contact with health services. Ex. Appendicitis in Acute appendicitis.

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64
Q

What are secondary terms?

A

These are ADJECTIVES and are lead term MODIFIERS. These may refer to anatomical site, variety or type of disease, etc. ex. Acute in acute appendicitis.

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65
Q

What is a word wheel?

A

Left of query window that contains alternate spellings or forms of words.

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66
Q

T or F. Secondary terms are listed under lead terms in alphabetical order.

A

T. Exception: secondary term “with” is almost always listed first.

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67
Q

T or F. Codes are assigned from the alphabetical index.

A

F. Codes are assigned from the tabular list. Hyperlinks in the AI lead to the possible list of codes. Always refer to the tabular list to review all inclusion notes, exclusion noted and supplemental info.

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68
Q

What are essential modifiers?

A

Essential secondary terms. These must be present in the documentation before the code can be assigned.

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69
Q

What are nonessential modifiers?

A

Additional terms in parentheses. The presence/absence of these terms in the source document doesn’t affect code selection.

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70
Q

What does the “next partition hit” icon do?

A

Small double arrow button to step from LEAD TERM to LEAD TERM.

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71
Q

What does the “next hit” icon do?

A

Large double arrow button to go from SUBTERM to SUBTERM within a lead term. Regular Ctrl + F

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72
Q

T or F. In some instances the coder must convert adjectival statements into a noun to find an appropriate code.

A

T. Ex. Deranged joint > Derangement, joint.

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73
Q

T or F. You can conduct a search on a secondary term only.

A

T. Do this when you can’t find a lead term in the AI and have exhausted all alternative terms

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74
Q

What does “specified NEC” indicate?

A

Not elsewhere classified. This is searched for as a secondary term when the secondary term can’t be located. The assignment of a sNEC code implies the documentation has described the condition in specific terms that fits with the axis of the category or subcategories but the classification doesn’t prove a depart specific code for the condition.

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75
Q

When do you use sNEC as a secondary term?

A

When1. A specific term used in documentation isn’t listed as a secondary term2. The term used FITS WITH THE AXIS of the category or subcategory3. The term can’t be assigned to a synonymous term

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76
Q

What does the residual category unspecified or NOS (not otherwise specified) indicate?

A

Assignment of an unspecified category implies that the documentation doesn’t provide the SPECIFIC INFO concerning the condition to permit assignment of a more specific code.

77
Q

When should you use unspecified or NOS categories?

A

ONLY when the document doesn’t provide the detail needed to assign the condition to a more specific category. The last resort.

78
Q

Where can instructional notes, inclusion notes, exclusion notes, and supplemental info be found?

A

In the code itself, beginnings of categories, blocks and chapters.

79
Q

T or F. You can assign an additional code to describe an excluded term as long as it represents an additional condition OR provides useful info and terms aren’t mutually exclusive.

A

T. Ex. Rectal fistula to skin and to vagina, codes:K60.4 Rectal fistulaN82.3 Fistula of vagina to large intestine

80
Q

T or F. The AI contains terms that aren’t included in the tabular list.

A

T. Accurate coding requires that both AI and TL be consulted prior to code assignment.

81
Q

T or F. Not all conditions significant to the current episode of care must be coded.

A

F. ALL conditions significant to episode of care must be coded.

82
Q

What coding options does ICD10CA provide when there is a relationship between conditions?

A
  1. Combination category2. Dual classification3. Use additional code instruction4. Code separately
83
Q

What is a primary code?

A

The code that describes the MOST FUNDAMENTAL ASPECT of the condition when multiple codes are required to describe it. It’s the code the classification considers as mandatory where only a single code can be assigned, like in mortality coding. Some instructions indicate that certain codes can’t be used in primary coding

84
Q

What are combination codes?

A

Combination codes are SINGLE codes that classify TWO conditions or a diagnosis with an associated manifestation or complication. Only the combo code is assigned when it FULLY identified the diagnostic conditions involved

85
Q

Where are combination codes usually located?

A

In the alphabetical index under secondary terms such as “with”, “due to”, “in”, and “complicating”.

86
Q

What is dual classification?

A

Dual classification is used for circumstances when there are two codes for diagnostic statements containing info about BOTH an underlying disease and a manifestation in a particular site which is a clinical problem in its OWN RIGHT.This etiology and manifestation are classified to separate chapters.

87
Q

What is the dagger/asterisk convention?

A

This is the term for dual classification codes. It allows for compilation of data on either aspect of an illness which is important in morbidity data where the manifestation is usually the reason for medical care.

88
Q

What does the dagger and asterisk stand for?

A

The dagger is the primary code and describes the etiology. The asterisk is the manifestation.

89
Q

T or F. Both codes in a dagger/asterisk code must be assigned.

A

T. The asterisk code may never be used alone.

90
Q

T or F. The asterisk code is always sequenced before the dagger code.

A

F. The dagger code is always sequenced first.

91
Q

When should one use an additional code?

A

When ICD10CA provides the instruction. Often used to identify ASSOCIATED factors in a condition such as the infecting organism, and conditions resulting from toxic agents.

92
Q

When should one code a condition separately?

A

When ICD10CA provided the instruction.

93
Q

What is the difference between a Use Additional Code instruction and a Code Separately Instruction?

A

“Use additional code” means assigning an additional code is MANDATORY. “Code separately” only when the additional code has an impact on the care and management of pt.

94
Q

What is he exception to Use Additional Code instruction

A

Codes in the b95-b98 block when used to describe infectious agents that aren’t drug resistant strains

95
Q

When should you use symptom codes?

A

When signs or symptoms remain undiagnosed at the end of an episode of care and he diagnosis is recorded this way.

96
Q

T or F. Codes for symptoms which are characteristic of the diagnosis are not assigned; only the code for the underlying condition.

A

T. Do not assign codes for symptoms which are characteristic of the diagnosis.

97
Q

How do we code unconfirmed diagnoses?

A

When a diagnosis is recorded in exploratory terms (possible, suspected, questionable, query, rule out) meaning the condition is still under investigation, the suspected diagnosis is coded as if established. A prefix Q is written before the IC code.

98
Q

When a final diagnosis is recorded as a symptom followed by a suspected diagnosis, how do we code this?

A

THE SYMPTOM IS CODED and a code for the suspected condition is added as supplemental info wig prefix Q.

99
Q

When do we not use Q for unconfirmed diagnoses?

A

When a diagnosis is recorded followed by statements relating to possible etiologies. Assign a code for the condition due to unspecified cause ONLY.

100
Q

What is the difference between “rule out” and “ruled out” in the documentation?

A

“Rule out” – the diagnosis is still considered to be possible”Ruled out” — diagnostic interventions have excluded the diagnosis as a possibility and isn’t coded.

101
Q

T or F. You can also use prefix Q when you are uncertain about the documentation.

A

F. The prefix is assigned only when the physician records the diagnosis in uncertain terms. It is NOT used when the coder is uncertain.

102
Q

How do we code a condition that is described as being both acute and chronic and there isn’t a combination code?

A

When ICD provides separate categories for chronic and acute but not a combination category, THE CODE FOR THE ACUTE CONDITION IS ASSIGNED. * use of additional code to describe the chronic condition is optional UNLESS each condition is treated separately.

103
Q

T or F. Sequelae codes are optional and assigned only when their presence adds significant clarification.

A

T.

104
Q

How might a sequelae be presented in the source document?

A

Terminology such as “old” “late effect of” or “due to previous”

105
Q

How are sequelae codes sequenced?

A

They are sequenced AFTER the code for the current problem. When there isn’t a current problem documented, the sequelae code may be assigned on its own.

106
Q

Why is “intervention” used instead of “procedure” in CCI classification?

A

Intervention reflects a broader scope across health services.

107
Q

How many codes are in CCI?

A

Approximately 18,000 codes listing DIAGNOSTIC, THERAPEUTIC, and SUPPORT interventions.

108
Q

What is the CCI tabular list?

A

Like icd10ca, the TL is the classification itself and is a list of intervention codes in alphanumeric order.

109
Q

T or F. Like icd10ca, CCI’s AI is a list of interventions leading to the codes in the tabular list.

A

T.

110
Q

How ate CCI and ICDCA software different?

A

CCI is expandable and can be updated to accommodate change. Blocks of codes have been reserved to allow for future growth. ICD isn’t expandable; requires new software about every 10 years

111
Q

T or F. CCI code structure uses code-building logic with a multi-axial framework.

A

T. The CODE STRUCTURE is designed to encompass different axes or criteria within one code. A coder could build a code by selecting a component from each of the axes.

112
Q

How is CCI organized?

A

CCI is organized into SECTIONS which are based on broad types of interventions. The first character of a CCI code represents the section.

113
Q

Which CCI section is not in use?

A

Section 4

114
Q

What do sections 1, 2, 3 and 5 stand for in CCI?

A
  1. Therapeutic Interventions 2. Diagnostic 3. DI^ further subdivided according to body system or anatomical site. These subdivisions are in field two. 5. ObsTODD
115
Q

How many fields are in a CCI code?

A

6.

116
Q

What do CCI fields contain?

A

Alpha and/or numeric characters separated by decimals and hyphens.

117
Q

What is the longest potential CCI code length?

A

10 characters

118
Q

What is the minimum amount of characters in a valid CCI code?

A

7.

119
Q

Basic Code Structure

A

46710: 4 minimum fields, 6 maximum fields, 7 minimum, 10 maximum charactersA.AA.AA.AA-BB-6Sec.Site.Intervention.Technique-Device-Type of TissueSSITDT

120
Q

Which group of fields is called the rubric and what do they describe?

A

Rubric: FIELDS 1-3; describes WHAT is being done.

121
Q

Which group of fields is called the qualifiers and what do they describe?

A

Qualifiers: Fields 4-6 describes HOW the intervention is fine

122
Q

What is the difference between the rubric and the qualifiers?/

A

RUBRIC+ QUALIFIERSWHAT IS DONE/HOW IT’S DONEF1-3+F4-6Rubrics are stable and won’t change over timeQualifiers are very dynamic as operative techniques and devices change with advancements in medical science and tech.

123
Q

What does Field 2 estand for?

A

Group. Contains 2 characters identifying a related grouping–body system or anatomical site. Also other subdivided ions in sections.

124
Q

What does Field 1 stand for?

A

Section.This field contains 1 character which represents the CCI section identifying the broad types of interventions.

125
Q

What does Field 3 stand for?

A

Intervention. Two characters identifying a generic intervention appropriate for each section (organ removal only in S1, counselling only in S6.

126
Q

What does Field 4 stand for?

A

Qualifier 1. Two characters, meanings section depended. In S1-3: approach or technique used. Ex. Open, endoscopic, percutaneous needle

127
Q

What does Field 5 stand for?

A

Qualifier 2. 2 chrctrs. Meanings section dependent. S1, 2 and 5 characters stand for devices or agents used.

128
Q

T or F. When this field isn’t required but a character is required in F6, F5 is XX.

A

T.

129
Q

What does Field 6 stand for?

A

Qualifier 3. 1 character. Meaning section dependent. Only applicable to s1-s8. Can be tissue used or type of strain.

130
Q

What does ^^ indicate?

A

An incomplete CCI code

131
Q

What are generic interventions?

A

General term used to identify the INTENT of the intervention even when the intervention can be described using multiple other terms. Partial excision acts for the several ways partial mastectomy could be described.

132
Q

T or F. CCI is opposite to ICDCA in that the tabular list contains more inclusion terms than the AI

A

T.

133
Q

CCI codes are located by searching the __________ first.

A

The tabular list via the advanced query (unnumbered bin). New coders should first use the AI First to help in developing generic int ml knowledge.

134
Q

T or F. The alphabetical index provides incomplete CCI codes.

A

F. AI provides incomplete codes. You must consult TL to complete codes.

135
Q

T or F. Folio doesn’t recognize hyphens.

A

T.

136
Q

T or F. In CCI the intervention is the lead term.

A

T. In most cases. Appendectomy angiogram work well as lead terms.

137
Q

Are interventions ALWAYS the lead term in CCI?

A

Not necessarily. Lead terms reflect the NATURE and INTENT of the intervention Ex. Suture laceration of the face. Intent: to repair the skin. Repair is the lead term. If unsure, search for suturing in AI which will lead you to see Repair.

138
Q

What are the secondary terms in CCI

A

The secondary terms are anatomic sites but could be a device, disordet, pregnancy stage. Skin and face are secondary terms.

139
Q

CCI Lead term + CCI secondary term

A

Intent of intervention+ site

140
Q

T or F. The coder finds instructional notes at the beginning of any change in characters in Field 3.

A

F. Beginning of Field 2.

141
Q

What are CCI intervention attributes?

A

In addition to the 10 character CCI code, intervention attributes contribute additional info related to the intervention.

142
Q

T or F. Intervention attributes are part of the code itself.

A

F. These attributed aren’t part of the code itself and are collected as separate data fields.

143
Q

T or F. Intervention attributes don’t apply to all CCI codes.

A

T.

144
Q

What are the intervention attributes?

A
  1. S— status. Info about the circumstances of the intervention (abandoned, revision, staged)2. L—location. Left right bilateral3. M—s5, 6, 7. 4. E—extent. Numbers and sizes
145
Q

What does pink yellow and grey mean re: int attributes?

A

Mandatory at the national level-pink and contain a null value. Optional unless S is true for the intervention-yellowAttribute doesn’t apply to rubric-grey

146
Q

What are CCI composite codes?

A

Eliminates the need to assign multiple codes to describe an intervention. These describe procedures that are commonly performed concomitantly.

147
Q

T or F. Elements of a procedure inherent to the intervention (drainage tubes, dressings) are always coded.

A

F. Not coded.

148
Q

T or f. Devices used and method of operative site closure are coded in the qualifier fields

A

T. These are pertinent to capture because EU are important for informing such things as operating room use and equipment needs

149
Q

T or F. Only assign a code as a result of a “code also” note when the additional procedure has been performed and the additional code describes an intervention mandatory for data collection.

A

T.

150
Q

What do you do when composite codes are unavailable?

A

An additional code from CCI is assigned to capture interventions performed. Mandatory multiple code: robotic assistance

151
Q

T or F. You must code each case device separately even under one intervention.

A

F. There is a hierarchy to follow. The coder must select he qualifier that is most significant for the reporting facility.

152
Q

T or F. When an intervention is performed on bilateral sites and there is no variation in any component of the CCI code, only one code is assigned.

A

T. When there is a variation in any component of the CCI code, assign SEPARATE codes for each intervention with the applicable location attribute for each. In this case more than one code from the same rubric will be require.

153
Q

When an intervention is performed that has both diagnostic and therapeutic purposes, only the code indicating the_______ intervention is assigned.

A

Therapeutic. Ex. A biopsy described as excisional is both diagnostic and therapeutic. Only code from S1 Aspiration of fluids is therapeutic

154
Q

T or F. Coding for imaging interventions when performed with a therapeutic procedure is required for ambulatory care data collection but not for inpatient data collection.

A

T.Exception: CORONARY ANGIOGRAMS must be coded whenever they are performed

155
Q

What is the difference in lead terms DILATION and DRAINAGE re: aren’t insertion?

A

Dilation is the lead term of the stent is inserted to maintain fluid flow via its NORMAL course. DRAINAGE is used when the stent is inserted to DIVERT the flow of fluids to an Alternate path.

156
Q

What is the difference between classifying pharmaceuticals as local or systemic via the vascular system?

A

When an agent is delivered by VEIN=SYSTEMIC, when delivered by ARTERY=LOCAL

157
Q

T or F. Insertion of a central venous catheter is mandatory when performed during the same episode of care.

A

T.

158
Q

What is a major component in the coding process?

A

Interpreting the source document, including determining what info is pertinent for capture and identifying the role of each diagnosis code in relation to the whole episode roc care.

159
Q

ICD code assignment guidelines relate to inpatient records largely while CCI has separate criteria for inpatient vs ambitious care coding.

A

T. There is a greater need to capture ambulatory care interventions over inpatient data collection because they have significant resource implication.

160
Q

What is required to code in CCI for ambulatory care interventions?

A

Almost all S1, most diagnostic interventions S2, ALL diagnostic imaging interventions from S3, immunisation procedures in S8. One is separate.

161
Q

What is pertinent for ICD-10-CA assignment?

A
  1. The most precise diagnosis2. Problems with SIGNIFICANTLY affect the care and resource use3. Conditions mandated for collection nationally and locally4. Symptoms and manifestations only when they are reason for care themselves or add to length of stay or alter treatment5. Important chronic problems and health indicators like diabetes, HTN /!; the problem influences resource use6. Past history when mandated
162
Q

What is pertinent for CCI coding (inpatient data)?

A
  1. S1 interventions performed in an OR, endoscopy suite, cardiac catherization rooms2. S1 int using open, endoscopic if per cutaneous transluminal, transartero approach 3. S2 inspection that is he sole intervention performed using OEP approach4. S2 biopsy as a sole intervention 5. S2 performed in the presence of an anaesthetist6. S3 performed in cat room (angiogram) or around anaesthetist
163
Q

What is pertinent for CCI coding— ambulatory care?

A
  1. S1 generic int number of 50 or higher (except per orifice catheter for bladder drains do percutaneous IV)2. S1 performed in operating room3. S1 performed under anaesthesia (including local an)4. S1 performed OEP approach5. S2 OEP, biopsy as sole int, sole int performed under any and thesis 6. S3 ALL INTERVENTIONS. Imaging using microscope optional ***when fluoroscopy and X-ray are performed at he same intervention ep, only X-ray assigned
164
Q

T or F. Specialised pharmaceutical interventions are mandatory for data collection such as chemotherapy and thrombolytic therapy.

A

T.

165
Q

Code cardiac arrest when resuscitation was performed or attempted. And the method of resuscitation.

A

T.

166
Q

ICD coding steps

A
  1. Analyse source 2. Select tentative code from AI3. Verify the code in TL4. Assign a diagnosis type
167
Q

CCI Coding steps

A
  1. Analyse source2. Select the rubric in AI3. Verify by TL4. Complete code qualifiers5. Assign attributesI
168
Q

ICD-10 was published by

A

World Health Organization

169
Q

Every ICD-10-CA code has at least __ characters

A

3

170
Q

Acute and chronic diseases would be coded as:

A

acute only or code acute first followed optionally by chronic

171
Q

Lead terms in CCI generally reflect the ___ of the intervention

A

intent

172
Q

Fields __ make up the rubric of the CCI code

A

1-3

173
Q

All CCI codes contain information in fields __ as a minimum

A

1-4

174
Q

Diagnosis recorded as “abdominal pain due to either obstructed bowel or diverticulitis”. Coding rule for abdominal pain is to code the pain as what diagnosis type?

A

MRDx

175
Q

What does .8 signify?

A

unspecified

176
Q

T or F. You may not code something found in a lap report.

A

T

177
Q

Insertion of a stent is classified to ___ by site when a new or alternate path is formed

A

drainage

178
Q

When interventions are both diagnostic and therapeutic in nature, only the ____ intervention should be coded

A

therapeutic

179
Q

Pharmacological agents adminstered via venous approach are classified as ___, while those administered via arterial are classified as ___

A

systemic, local

180
Q

Dysphagia due to old cerebral infarction. Which is the sequelae?

A

dysphagia

181
Q

Describe the three dimensions of accuracy in data classification.

A

-

182
Q

List two factors that influence quality and reliability of data.

A

-

183
Q

__ and __ in classification are key to ensuring data that is of sufficient quality to permit use with a high level of confidence

A

accuracy and consistency

184
Q

Quality is measured in terms of ___, that the same results can be achieved in repeat attempts

A

reliability

185
Q

Quality is influenced by which factors?

A
  1. quality of the classification system
  2. quality of the source document
  3. skill of the coder
  4. establishment of and compliance with rules and standards
  5. editing capabilities of data collection software
186
Q

Accuracy of code assignment can be viewed as consisting of which three dimensions?

A
  1. individual codes
  2. totality of codes
  3. sequence/typing of codes
187
Q

Accuracy dimension: assignment of an alphanumerical code to individual diagnosis or intervention statements must be accurate

A

individual codes

188
Q

Accuracy dimension: codes necessary to give an accurate clinical patient of a patient’s episode of care must be assigned and designated appropriately by diagnosis type

A

totality of codes

189
Q

Accuracy dimension: codes must have a diagnosis type and be organized in a sequence such that it is possible to identify multiple codes used to describe one condition to perceive the significance of conditions in relation to resource use and to understand the chronology of events pertaining to the patient’s episode of care

A

sequence/typing of codes

Z. CDAB 1 (5 decks)

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