ICD-10 Ch. 4-5

Question 1

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.

Answer 1

electronic Health Record (EHR)

Question 2

Patient information document found on Inpatient, Outpatient, and Long Term Care health care records.

Answer 2

facesheet

Question 3

Age, gender, and address information used for statistical purposes.

Answer 3

demographics

Question 4

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.

Answer 4

history and physical

Question 5

Documentation usually completed by attending physician that summarizes the details of the hospitalization/encounter.

Answer 5

discharge summary

Question 6

Documentation of the opinion and any treatment plan provided by a specialist in the field of the consultation is required.

Answer 6

consultation report

Question 7

Documentation of the surgical procedure details.

Answer 7

operative report

Question 8

Documentation that provides description and pathological diagnosis of specimens submitted for review from an operative procedure.

Answer 8

pathology report

Question 9

Documentation of prescribed medications, therapies, consultation requests and other treatments that the physician feels are necessary to care for and treat the patient.

Answer 9

physician orders

Question 10

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.

Answer 10

progress notes

Question 11

A progress note with subjective, objective, assessment and plan.

Answer 11

SOAP note

Question 12

Component of SOAP note that is the patient’s statement of why they are seeking care and how they feel.

Answer 12

subjective

Question 13

Component of SOAP note that is based on the observations of the healthcare professional.

Answer 13

objective

Question 14

Component of SOAP note that contains diagnosis information

Answer 14

assessment

Question 15

Component of SOAP note that contains how patient will be treated and any treatments to be performed to help clarify the diagnosis.

Answer 15

plan

Question 16

Nursing and ancillary clinical staff documentation of care and services provided to the patient and their response to such.

Answer 16

nursing notes

Question 17

List of medications that describes what was ordered and subsequently given to the patient.

Answer 17

medication administration records (MAR)

Question 18

Disease or other medical condition; why the patient was admitted and/or evaluated?

Answer 18

diagnosis

Question 19

Medical care rendered to a patient during an encounter consisting of an examination, test, therapeutic treatment, or surgery; what was done?

Answer 19

procedure

Question 20

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.

Answer 20

medical necessity

Question 21

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

Answer 21

query

Question 22

Term searched for in the ALPHABETIC index to locate the necessary corresponding code.

Answer 22

main term

Question 23

Term used to modify the main term when looking up clodes.

Answer 23

subterm

Question 24

Unit of the codebook dedicated to a GROUP of diagnoses.

Answer 24

chapter

Question 25

Group of CATEGORIES that include similar conditions.

Answer 25

section

Question 26

Effect of medical conditions/injuries that may require additional treatment or impact other conditions later in life.

Answer 26

late effect

Question 27

Term used in coding to refer to a late effect. (i.e. weakness as a late effect of a previous stroke)

Answer 27

sequela

Question 28

Condition established AFTER study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Answer 28

principal diagnosis

Question 29

Two or more comparing or contrasting diagnoses.

Answer 29

differential diagnosis

Question 30

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.

Answer 30

secondary diagnosis

Question 31

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.

Answer 31

encounter

Question 32

Term used in the OUTPATIENT setting in place of “principal diagnosis (inpatient)”.

Answer 32

first listed diagnosis

Question 33

T/F - Physician and nonphysician documentation must be reviewed for coding.

Answer 33

True

Question 34

Body mass index and pressure ulcer code assignment may be based on non-physician documentation if what?

Answer 34

A physician has already made an actual diagnosis.

Question 35

Difference between diagnosis and procedure.

Answer 35

Diagnosis: Why was patient admitted. Why was a procedure done.

Procedure: What was done.

Question 36

If a definitive diagnosis has been established, it is appropriate to assign codes for signs and symptoms of that diagnosis?

Answer 36

no

Question 37

Should diagnoses listed as “possible”, “probable”, “suspected” or “rule out” be coded in the INPATIENT setting? OUTPATIENT setting?

Answer 37

Inpatient - yes

Outpatient - no

Question 38

Obtaining a profession coding credential is a method of demonstrating that you have achieved what as a professional coder.

Answer 38

competence

Question 39

What should a coder always do to verify the code selection is appropriate and to the highest level of specificity?

Answer 39

cross-reference the tabular list

Question 40

When a code is located in the TABULAR list, what else should a coder do??

Answer 40

Look for additional instructional terms, notes, etc.

Question 41

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?

Answer 41

Code pneumonia because it is the reason for the chest pain. Do not code the chest pain.

Question 42

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.

Answer 42

Should be coded.

Question 43

Should uncertain diagnoses be coded in the outpatient setting? If no, then what to do? Ex. Fever, rule out bronchitis.

Answer 43

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.