Cumulative Exam Flashcards
1
Q
What is coding?
A
Transforming verbal descriptions of diseases, injuries, and procedures into characters.
2
Q
What is the purpose of coding?
A
Assigning a character to diagnoses and procedures for retrieval, research, and reimbursement.
3
Q
What are the internal demands for health information?
A
Health record abstracts, claim forms, employee profiles, disease and procedure indices, managed care.
4
Q
What are the external demands for health information?
A
Third party payers, outside agencies, customers, forecast and evaluate utilization of facilities, appropriateness of facilities, appropriateness of costs, physician profiles.
5
Q
What are the characteristics of data quality?
A
Reliable, valid, complete, timely.
6
Q
What is a Principal Diagnosis?
A
The condition established, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
7
Q
What is a Secondary Diagnosis?
A
All conditions that coexist at the time of admission or develop subsequently.
8
Q
What is a comorbidity?
A
A pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in length of stay.
9
Q
What is a complication?
A
A condition that arises during the hospital stay that prolongs the stay.
10
Q
What is a Principal Procedure?
A
One which is performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. Usually related to the principal diagnosis.
11
Q
What is a Secondary Procedure?
A
All other significant procedures.
12
Q
What does ICD-10 CM stand for?
A
International Classification of Diseases, Tenth Revision, Clinical Modification.
13
Q
What does ICD-10 PCS stand for?
A
International Classification of Diseases, Tenth Revision, Procedure Coding System.
14
Q
Who are the cooperating parties for ICD-10?
A
CMS, NCHS, AHA, AHIMA.
15
Q
What is the implementation date for ICD-10?
A
Oct. 1, 2014
16
Q
Who developed ICD-10 PCS?
A
3M
17
Q
How many characters are in a CM code?
A
3-7
18
Q
Where is the decimal point located in a CM code?
A
Between the third and fourth character.
19
Q
What do CM codes start with?
A
An alpha character.
20
Q
What is the placeholder in CM?
A
X
21
Q
How many characters are in a PCS code?
A
7
22
Q
What is a section in CM?
A
Groups of three-character categories
23
Q
What is a category in CM?
A
Three-character code numbers
24
Q
What is a subcategory in CM?
A
Four-character code numbers
25
What is a subclassification in CM?
Fifth, sixth and seventh character code numbers
26
What is the tabular list in CM?
A chronological list of codes divided into chapters based on body system or condition.
27
What is the alphabetic index in CM?
An alphabetic list of terms and their corresponding code.
28
What are Includes notes in CM?
Further define or give examples of the content of a chapter, section or category.
29
What are "excludes 1" in CM?
NOT CODED HERE. A code should never be used at the same time as a code above the excludes 1.
30
What are "excludes 2" in CM?
NOT INCLUDED HERE. Condition excluded is not part of the condition represented by the code; however, a patient may have both conditions. May use both codes.
31
What does "code first" mean in CM?
Indicates sequencing-i.e. etiology.
32
What does "code second" mean in CM?
Indicates sequencing-i.e. manifestation
33
What does "code also" mean in CM?
Two codes may be required.
34
What does "NEC" stand for and mean?
Not Elsewhere Classified. May need to look elsewhere for the code.
35
What does "NOS" stand for and mean?
Not Otherwise Specified. Lack of specific information in the record.
36
What does "see" mean in CM?
Refer to another term.
37
What does "see also" mean in CM?
Can refer to another place in the index.
38
What does "see category" in CM mean?
Provides a category number to refer to in the tabular list.
39
What do parenthesis in CM represent?
Nonessential Modifiers. Supplementary words or explanatory information may be either present or absent in the diagnostic statement. Do not affect the code.
40
What are nonessential modifiers in CM?
Listed as subterms and affect the code.
41
What do square brackets represent in CM?
Enclose synonyms, alternative wordings, abbreviations, and explanatory phrases for additional information. Like parentheses and not required for the statement of diagnosis.
42
What does a colon represent in CM?
Used after an incomplete term that needs one or more modifiers following the colon in order for the term to apply.
43
What does "and" mean in CM?
And/or
44
What does "with" mean in CM?
Associated with or due to
45
What does "due" to mean in CM?
Causal relationship between two conditions. The diagnostic statement must indicate this relationship.
46
What does UHDDS stand for?
Uniform Hospital Discharge Data Set
47
What is the UHDDS?
It is used for reporting inpatient data in acute care, short-term care, and long-term care hospitals.
48
What are the three items that the UHDDS require?
Principal diagnosis, other diagnoses, all significant procedures.
49
You assign codes to the _______ level of detail?
Highest
50
What does "rule out" signify?
A diagnosis is still considered to be possible.
51
What does "ruled out" signify?
A diagnosis is no longer a possibility.
52
What is a late affect?
A residual condition that remains after the termination of the acute phase of an illness or injury.
53
Late affect codes can be found by referring to the main term _______?
Sequelae
54
What are the two codes that are needed for late affects?
The condition or the nature of the late effect and the late effect code.
55
What is the code structure of a PCS code?
Alphanumeric
56
What does the first character in a PCS code represent?
Section
57
What does the second character in a PCS code represent?
Body system
58
What does the third character in a PCS code represent?
Root operation
59
What does the fourth character in a PCS code represent?
Body part
60
What does the fifth character in a PCS code represent?
Approach
61
What does the sixth character in a PCS code represent?
Device
62
What does the seventh character in a PCS code represent?
Qualifier
63
What is a section in PCS?
A broad procedure category or section where the code is found.
64
How many sections are in PCS?
16
65
What are the sections in PCS?
Medical and surgical, obstetrics, placement, administration, measurement and monitoring, extracorporeal assistance and performance, extracorporeal therapies, osteopathic, other procedures, chiropractic, imaging, nuclear medicine, Radiation oncology, rehabilitation and audiology, mental health, substance abuse.
66
What is a root operation in PCS?
The objective of the procedure.
67
How many root operations are there?
31
68
What does the root operation "occlusion" mean?
Completely closing an orifice or the lumen of a tubular body part.
69
What does the root operation "supplement" mean?
Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part.
70
What does the root operation "restriction" mean?
Partially closing an orifice or the lumen of a tubular body part.
71
What does the root operation "removal" mean?
Taking out or off a device from a body part.
72
What does the root operation "repair" mean?
Restoring, to the extent possible, a body part to its normal anatomic structure and function.
73
What does the root operation "fusion" mean?
Joining together portions of an articular body part rendering the articular body part immobile.
74
What does the root operation "division" mean?
Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part.
75
What does the root operation "extirpation" mean?
Taking or cutting out solid matter from a body part.
76
What does the root operation "dilation" mean?
Expanding an orifice or the lumen of a tubular body part.
77
What does the root operation "bypass" mean?
Altering the route of passage of the contents of a tubular body part.
78
What does the root operation "Creation" mean?
Making a new genital structure that does not physically take the place of a body part.
79
What does the root operation "transplantation" mean?
Putting in or on, all or portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part.
80
What does the root operation "insertion" mean?
Putting in a non-biological device that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part.
81
What does the root operation "fragmentation" mean?
Breaking solid matter in a body part into pieces.
82
What does the root operation "excision" mean?
Cutting out, or off, without replacement, a portion of a body part.
83
What does the root operation "drainage" mean?
Taking or letting out fluids and/or gases from a body part.
84
What does the root operation "destruction" mean?
Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.
85
What does the root operation "map" mean?
Locating the route of passage of electrical impulses and/or locating functional areas in a body part.
86
What does the root operation "extraction" mean?
Pulling or stripping out or off all or a portion of the body part by the use of force.
87
What does the root operation "change" mean?
Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or mucous membrane.
88
What does the root operation "inspection" mean?
Visually and/or manually exploring a body part.
89
What does the root operation "release" mean?
Freeing a body part from an abnormal physical constraint by cutting or by use of force.
90
What does the root operation "altercation" mean?
Modifying the natural anatomic structure of a body part without affecting the function of the body part.
91
What does the root operation "resection" mean?
Cutting out or off, without replacement, all of a body part.
92
What does the root operation "reattachment" mean?
Putting back in or on all or a portion of a separated body part to its normal location or other suitable location.
93
What does the root operation "transfer" mean?
Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part.
94
What does the root operation "control" mean?
Stopping, or attempting to stop, postprocedural bleeding.
95
What does the root operation "reposition" mean?
Moving all or a portion of a body part to its normal location or other suitable location.
96
What does the root operation "detachment" mean?
Cutting off all or part of the upper or lower extremities.
97
What does the root operation "replacement" mean?
Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
98
What does the "approach" character in PCS mean?
The technique or approach used to reach the procedure site.
99
How many approaches are there in PCS?
7
100
What are the different approaches in PSC?
External, open, percutaneous, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic, via natural or artificial opening with percutaneous endoscopic assistance.
101
What does the approach "external" mean?
Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane.
102
What does the approach "open" mean?
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
103
What does the approach "percutaneous" mean?
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.
104
What does the approach "percutaneous endoscopic" mean?
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.
105
What does the approach "via natural or artificial opening" mean?
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.
106
What does the approach "via natural or artificial opening endoscopic" mean?
Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.
107
What does the approach "via natural or artificial opening with percutaneous endoscopic assistance" mean?
Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.
108
In PCS, only devices that ________ are coded?
Remain in or on the patient's body after the procedure is completed.
109
What are the four categories of devices in PCS?
Grafts and prostheses, implants, simple or mechanical appliances, electronic appliances.
