Cumulative Exam Flashcards
What is coding?
Transforming verbal descriptions of diseases, injuries, and procedures into characters.
What is the purpose of coding?
Assigning a character to diagnoses and procedures for retrieval, research, and reimbursement.
What are the internal demands for health information?
Health record abstracts, claim forms, employee profiles, disease and procedure indices, managed care.
What are the external demands for health information?
Third party payers, outside agencies, customers, forecast and evaluate utilization of facilities, appropriateness of facilities, appropriateness of costs, physician profiles.
What are the characteristics of data quality?
Reliable, valid, complete, timely.
What is a Principal Diagnosis?
The condition established, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
What is a Secondary Diagnosis?
All conditions that coexist at the time of admission or develop subsequently.
What is a comorbidity?
A pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in length of stay.
What is a complication?
A condition that arises during the hospital stay that prolongs the stay.
What is a Principal Procedure?
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.
What is a Secondary Procedure?
All other significant procedures.
What does ICD-10 CM stand for?
International Classification of Diseases, Tenth Revision, Clinical Modification.
What does ICD-10 PCS stand for?
International Classification of Diseases, Tenth Revision, Procedure Coding System.
Who are the cooperating parties for ICD-10?
CMS, NCHS, AHA, AHIMA.
What is the implementation date for ICD-10?
Oct. 1, 2014
Who developed ICD-10 PCS?
3M
How many characters are in a CM code?
3-7
Where is the decimal point located in a CM code?
Between the third and fourth character.
What do CM codes start with?
An alpha character.
What is the placeholder in CM?
X
How many characters are in a PCS code?
7
What is a section in CM?
Groups of three-character categories
What is a category in CM?
Three-character code numbers
What is a subcategory in CM?
Four-character code numbers
What is a subclassification in CM?
Fifth, sixth and seventh character code numbers
What is the tabular list in CM?
A chronological list of codes divided into chapters based on body system or condition.
What is the alphabetic index in CM?
An alphabetic list of terms and their corresponding code.
What are Includes notes in CM?
Further define or give examples of the content of a chapter, section or category.
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.
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.
What does “code first” mean in CM?
Indicates sequencing-i.e. etiology.
What does “code second” mean in CM?
Indicates sequencing-i.e. manifestation
What does “code also” mean in CM?
Two codes may be required.
What does “NEC” stand for and mean?
Not Elsewhere Classified. May need to look elsewhere for the code.
What does “NOS” stand for and mean?
Not Otherwise Specified. Lack of specific information in the record.
What does “see” mean in CM?
Refer to another term.
What does “see also” mean in CM?
Can refer to another place in the index.
What does “see category” in CM mean?
Provides a category number to refer to in the tabular list.
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.
What are nonessential modifiers in CM?
Listed as subterms and affect the code.
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.
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.
What does “and” mean in CM?
And/or