ICD-10 Ch. 4-5 Flashcards
Ch. 4-5 Review
Automated health record document that includes digital images, point of care documentation by providers, clinical decision support, and the ability to to be accessed by multiple users at the same time.
electronic Health Record (EHR)
Patient information document found on Inpatient, Outpatient, and Long Term Care health care records.
facesheet
Age, gender, and address information used for statistical purposes.
demographics
Documentation of the patient’s chief complaint, past medical history, social history, surgical history, family history, review of systems, physical examination, assessment of patient’s problems, and treatment plan.
history and physical
Documentation usually completed by attending physician that summarizes the details of the hospitalization/encounter.
discharge summary
Documentation of the opinion and any treatment plan provided by a specialist in the field of the consultation is required.
consultation report
Documentation of the surgical procedure details.
operative report
Documentation that provides description and pathological diagnosis of specimens submitted for review from an operative procedure.
pathology report
Documentation of prescribed medications, therapies, consultation requests and other treatments that the physician feels are necessary to care for and treat the patient.
physician orders
Notes provided by physicians and other providers to document the progress of the patient throughout the entire encounter. These must also be dated and timed when the entry is made in association with JCAHO standards.
progress notes
A progress note with subjective, objective, assessment and plan.
SOAP note
Component of SOAP note that is the patient’s statement of why they are seeking care and how they feel.
subjective
Component of SOAP note that is based on the observations of the healthcare professional.
objective
Component of SOAP note that contains diagnosis information
assessment
Component of SOAP note that contains how patient will be treated and any treatments to be performed to help clarify the diagnosis.
plan
Nursing and ancillary clinical staff documentation of care and services provided to the patient and their response to such.
nursing notes
List of medications that describes what was ordered and subsequently given to the patient.
medication administration records (MAR)
Disease or other medical condition; why the patient was admitted and/or evaluated?
diagnosis
Medical care rendered to a patient during an encounter consisting of an examination, test, therapeutic treatment, or surgery; what was done?
procedure
Term used by payers to define the need for each procedure code submitted. At least one diagnosis code should be used for each procedure to describe why that procedure, test, exam, etc., needs to be performed.
medical necessity
Question posed to physician regarding the need for for further documentation/specification in order to assign the code that should be used for each procedure to describe why that procedure, test, exam, etc. needs to be performed
query
Term searched for in the ALPHABETIC index to locate the necessary corresponding code.
main term
Term used to modify the main term when looking up clodes.
subterm
Unit of the codebook dedicated to a GROUP of diagnoses.
chapter
Group of CATEGORIES that include similar conditions.
section
Effect of medical conditions/injuries that may require additional treatment or impact other conditions later in life.
late effect
Term used in coding to refer to a late effect. (i.e. weakness as a late effect of a previous stroke)
sequela
Condition established AFTER study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
principal diagnosis
Two or more comparing or contrasting diagnoses.
differential diagnosis
Diagnosis/conditions that impact patient care due to: extending length of stay, requiring clinical evaluation or tx., increasing care and/or monitoring, coexisting at the time of admission, developing after admission.
secondary diagnosis
Term used to describe each time a patient presents for care. A patient has an “encounter” number for each account. All encounter numbers fall under the med red # in the master patient index.
encounter
Term used in the OUTPATIENT setting in place of “principal diagnosis (inpatient)”.
first listed diagnosis
T/F - Physician and nonphysician documentation must be reviewed for coding.
True
Body mass index and pressure ulcer code assignment may be based on non-physician documentation if what?
A physician has already made an actual diagnosis.
Difference between diagnosis and procedure.
Diagnosis: Why was patient admitted. Why was a procedure done.
Procedure: What was done.
If a definitive diagnosis has been established, it is appropriate to assign codes for signs and symptoms of that diagnosis?
no
Should diagnoses listed as “possible”, “probable”, “suspected” or “rule out” be coded in the INPATIENT setting? OUTPATIENT setting?
Inpatient - yes
Outpatient - no
Obtaining a profession coding credential is a method of demonstrating that you have achieved what as a professional coder.
competence
What should a coder always do to verify the code selection is appropriate and to the highest level of specificity?
cross-reference the tabular list
When a code is located in the TABULAR list, what else should a coder do??
Look for additional instructional terms, notes, etc.
T/F Abnormal finding diagnoses should/should not be coded simple from documentation. Ex. Chest pain leads to x-ray which shows pneumonia. What to code?
Code pneumonia because it is the reason for the chest pain. Do not code the chest pain.
Uncertain diagnosis should/should not be coded in the INPATIENT setting if they were truly established and are still questionable at the time of the patient’s discharge.
Should be coded.
Should uncertain diagnoses be coded in the outpatient setting? If no, then what to do? Ex. Fever, rule out bronchitis.
No. Code the related signs, symptoms, abnormal results or other known reason for the visit. Code the fever because the bronchitis has not been established and needs to be ruled out.
