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ASAP > Coding > Flashcards

Coding Flashcards

1
Q

SEE

A

To refer another term

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2
Q

SEE ALSO

A

Refer another term if you full information is not located under the 1st term

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3
Q

MULTIPLE CODES

A

Use of more than one code for the identification of complex diagnostic statement s

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4
Q

COMBINATION CODES

A

One code for dx with secondary manifestation or associated complication

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5
Q

NON ESSENTIAL MODIFIERS

A

Subs that follow the main term in closed parenthesis

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6
Q

NON ESSENTIAL MODIFIERS

A

Subs that follow the main term in closed parenthesis

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7
Q

ESSENTIAL MODIFIERS

A

Sub terms under main term that are in alphabetic order and intended

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8
Q

Boxed tick

A

Incomplete code

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9
Q

7th Character A D S

A

A- initial encounter
D - Subsequent encounter
S - sequela

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10
Q

Example of sequela

A

Complication or late effect of an injury
Scar formation after a burn

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11
Q

Types of codes

A

Specified
Unspecified
Specified NEC

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12
Q

NOS

A

Not otherwise specified
Unspecified

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13
Q

NEC

A

Not elsewhere classified
Other specified codes
No specific code to represent the condition

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14
Q

Types of medical coding

A

ICD
CPT
HCPS

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15
Q

PLACE HOLDER

A

X
to fill 6th position to code with 7th character

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16
Q

IMPENDING / THREATENED CONDITION

A

conditions / risk at time of discharge

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17
Q

Guidelines of impending conditions

A
  • if condition occurred, code as confirmed dx
  • if condition not occurred yet, code as impending
  • if impending condition not listed, assign code for underlying condition
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18
Q

Guideline for borderline dx

A

If there is no borderline index, then code as confirmed dx

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19
Q

What is 7th character ?

A

Additional information required to complete the code

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20
Q

what is coma?

A

deep state of unconsciousness

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21
Q

what is coma scale called ?

A

glassgow scale

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22
Q

what is glassgow scale used for ?

A

to measure the level of unconsciousness in a coma patient

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23
Q

guideline for coma codes?

A

(1) dx code first, coma code second, glassgow score code third.
(2) if multiple coma scores are documented, code coma score at the time of admission only.
(3) 7th character indicates when the coma scale was recorded.
(4) Non traumatic coma - code underlying condition first.

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24
Q

what is disease?

A

any harmful deviation from the normal structural and functioning state of an organism

25
what is a sign ?
any objective evidence of a disease that can be observed by someone other than the patient.
26
symptom
any subjective evidence that is experienced by the patient only.
27
guidelines for coding signs and symptoms?
(1) When there is a confirmed dx documented, then code for the dx (2) when there is no confirmed dx documented, code as signs and symptoms (3) when there is possible dx or probable dx documented, code as signs and symptoms only.
28
Guidelines for coding kidney diseases
(1) if both CKD and ESRD are documented, code for ESRD only (2) if CKD 5 + chronic renal dialysis is documented, code as ESRD (3) If CKD + renal dialysis is documented, code appropriately for CKD and dialysis seperately.
29
Guidelines for BPH
(1) if pt has dx of BPH + symptoms other than LUTS, code as BPH, signs and symptoms only (2)
30
Guidelines for EAR
(1) Code specifically for laterality of ears (2) if both L and R ears documented, code as Bilaterla (3) if side is not mentioned, code as unspecified
31
Types of Otitis Media
Acute Otitis Serous Otitis Media / Otitis media with effusion Chronic Otitis Media
32
What is glaucoma ?
disease that damages the optic nerve due to buildup of eye fluids.
33
Main classifications of glaucoma ?
open angle glaucoma closed angle glaucoma
34
types of glaucoma
normal tension glaucoma low tension glaucoma pigmented glaucoma secondary glaucoma
35
Guidelines for coding glaucoma
(1) compulsorily identify and code for type, stage, side (2) if stage of glaucoma is not documented, code as unspecified (3) if stage cannot be determined, code as indeterminate stage. (4) if both eyes are affected with the same stage and same type pf glaucoma, code as bilateral. (5) if pt has bilateral glaucoma but if the stage or type is different, code appropriately for each. (6) if pt is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented.
36
what is cataract ?
cloudy/opaque area in the lens of the eye
37
guidelines of cataract
if cataract is not documented as age related, then don't code as age related cataract even if the pt is senile.
38
what is pressure ulcer ?
injuries to skin and underlying tissue resulting from prolonged pressure on the skin
39
guidelines for pressure ulcers ?
(1) code for stages of pressure ulcer (2) if stage cannot be determined clinically, then document as unstageable. (3) pressure ulcers are combination codes (4) if pressure ulcer is documented as healing, then code for stage of the pressure ulcer only. Don't code for healing. (5) if pressure ulcer was documented at the time of admission and it healed completely during the stay, then code for the stage at time of admission (6) if pt is admitted and stage progresses during the stay, code stage at time of admission first, then code for the progressed stage as second. (7) if stage is unstageable first and the revealed after debridement, assign code for stage after debrediment.
40
What are status codes ?
Status codes are Z codes used when a patient visits a healthcare provider for reasons other than an injury or pathology
41
What are status codes ?
Status codes are Z codes used when a patient visits a healthcare provider for reasons other than an injury or pathology
42
Example of status code
Routine healthcare examination
43
What are psychoactive substances?
Substances which when taken into one’s system, affects the mental health process.
44
What is substance abuse?
refers to when an individual who uses drugs, even though they are aware of it having an adverse effect on their health and well being.
45
what is substance dependence ?
it is when an individual develops tolerance to a particular substance upon repeated use and shows withdrawal symptoms on stopping or reducing that particular substance
46
what is withdrawal symptom?
unpleasant physical and mental illness experienced by a substance addict on stopping or reducing that particular substance
47
Guidelines for use (U), abuse (A) and dependence.(D)
(1) If U, and A documented, code for A (2) If U and D documented, code for D (3) If A and D documented, code for D (4) If U, A and D documented, code for D.
48
What is poisoning ?
Poisoning occurs when any substance interferes with the normal bodily functions, when swallowed, inhaled, injected or absorbed.
49
Guidelines for poisoning ?
(1) If the intent is unspecified or unknown, code as accidental (2) if intent is documented as cant be determined, code as undetermined. (3) First code for the poisoning, second code for manifestation
50
51
What is adverse effect ?
ill reaction to a drug taken correctly by the patient on correct prescription
51
what is underdosing?
take less dose of a medication, prescribed by the doctor
51
Guideline for adverse effect ?
(1) code for manifestation (2) code for adverse effect (3) code for purpose of taking the drug
52
guidelines for underdosing ?
(1) code for manifestation of underdosing (2) code for underdosing (3) code for purpose of taking the drug
53
What is neoplasm ?
abnormal growth of tissue
54
types of neoplasm ?
(1) Benign - non cancerous (2) Malignant - cancerous (3) uncertain -not cancerous yet but has the potential to be cancerous (4) unspecified - not specified
55
Types of malignant neoplasm
(1)primary - cancer in primary site, has not spread (2) secondary - secondary site where cancer has spread (3) carcinoma in situ - stayed in primary site and will not spread
56
Guideline for neoplasm

ASAP (19 decks)

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