Lesson 6

Question 1

ICD-10-PCS

Answer 1

Is a coding system developed by centers for Medicare and Medicaid services for coding procedures in inpatient hospital settings only.

Question 2

Index to diseases and injuries

Answer 2

An alphabetic list of terms and their corresponding codes. It also includes a table of neoplasms, table of drugs and chemicals, and an index to external clauses of injuries.

Known also as alphabetical Index

Question 3

Tabular list

Answer 3

A list of codes and code descriptions divided into chapters

Question 4

Main terms

Answer 4

In the index are boldfaced, capitalized, flush with the left margin and in alphabetical order.

Question 5

Nonessential modifiers

Answer 5

Sometimes next to the main term. Which are supplementary words located in parentheses after a main term and do not have to be Included in the diagnostic statement for the code to be assigned.

Question 6

Sub terms

Answer 6

Are indented underneath main terms and they further describe the condition.

Question 7

Qualifiers

Answer 7

Are terms that are indented under subterms and provide additional i formation.

Question 8

Neoplasm

Answer 8

Means new growth and refers to an abnormal mass of tissue that results when cel reproduction is out of control. It is also called a tumor.

Question 9

Malignant primary

Answer 9

A malignant tumor is cancerous and capable of spreading to other parts of the body. A primary malignancy is the original tumor site. All malignant tumors are considere primary unless otherwise documented as metastatic or secondary.

Question 10

Secondary malignancy

Answer 10

The tumor has metastasized (spread) to a secondary site, either adjacent to the primary site or to a remote region of the body. For example a patient who has prostate cancer that has metastasized to the bone has a primary prostate cancer and a secondary bone cancer.

Question 11

Carcinoma (Ca) in situ

Answer 11

A malignant tumor that is contained at the original site. (Has not spread)

Question 12

Benign

Answer 12

A non cancerous neoplasm that is not life threatening

Question 13

Uncertain behavior

Answer 13

The pathologist will not be able to make a definite diagnosis about the behavior of the neoplasm

Question 14

Unspecified behavior

Answer 14

The documentation doesn’t support a more specific code or results are pending.

Question 15

Laterality

Answer 15

A term that indicates whether a condition affects one side of the body or the other

Question 16

Encounter

Answer 16

The face to face contact between a patient and a healthcare provider who assesses and treats the patients condition.

Question 17

Neoplasm

Answer 17

Means “new growth”, and refers to ah abnormal mass of tissue that results when cell reproduction is out of control

Question 18

Eponym

Answer 18

A disease or condition names after the person who identified it

Question 19

Etiology

Answer 19

The cause of a disease

Question 20

Manifestation

Answer 20

A condition or complication caused by another condition or disease

Question 21

Excludes1

Answer 21

Indicates that two specific conditions cannot be coded Togethor for the same encounter

Question 22

Excludes2

Answer 22

Indicates that a specific condition is not included here, but the two conditions can be coded separately

Question 23

Combination code

Answer 23

A single code used to classify two diagnoses

Question 24

GEMs

Answer 24

General equivalence mappings. Are translation dictionaries or crosswalks of codes that can be used to roughly identify icd-10-cm codes from their icd-9-cm codes and vice versa

Question 25

Mortality

Answer 25

Death

Question 26

Morbidity

Answer 26

Disease

Question 27

What are the two current outpatient coding systems

Answer 27

1. Icd-10-cm for diagnoses.
   Internacional classification of diseases, tenth revision, clinical modification

2.hcpcs (healthcare common procedure coding system )
-hcpcs level 1, called current procedural terminology (cpt) got procedures and services.
-hcpcs level 2 for services and supplies not listen in cpt

Question 28

Icd-10-pcs

Answer 28

Is a coding system developed by centers for Medicare and Medicaid services for coding procedures in inpatient hospital settings only.

Question 29

WHO

Answer 29

World health organization

Question 30

NCHS

Answer 30

The national center for health statistics

Question 31

Benefits of icd-10-cm

Answer 31

-It provided greater coding accuracy and specificity.
-it contains a multitude of descriptions relevant to out patient care
-It’s / flexible enough to allow for expansion
-It’s up to date with current standard
-it meets hippa’s EDI standards and the need of current payment systems
-it aligns the u.s. goring system with those worldwide

Question 32

Icd-10-cm has key features to be aware of

Answer 32

Codes may be 3, 4, 5, 6, or 7 characters in length.

First character is always a letter. All letters are used except “u”

Additional characters Can be numbers or letters

Codes include laterality, or specific side of body (right shoulder, left eye), where applicable