vocab Flashcards
etiology
the cause, set of cause, or manner of causation of a disease or condition
manifestation
describes the manifestation(Sign or The display or disclosure of characteristic signs or symptoms of an illness) of an underlying disease, not the disease itself, and therefore, cannot be a principal diagnosis.
7th characters and place holder
codes less than 6 characters that require a 7th character a placeholder X is assigned for all character less than 6
7th character A
initial encounter - all encounters involving diagnosis and treatment
7th character D
subsequent encounter - encounters during the healing phase
7th character S
sequela
which diagnosis is used in an outpatient setting first
first list diagnosis is used in lieu of principal diagnosis
chapter 21 Z codes are
factors influencing health status and cotact with health services Z00-Z99
T/F certain Z codes may ony be used as 1st listed or principal diagnosis
true
T/F Z codes indicate a reason for an encounter
true
T/F Z codes are not procedure codes
true a corresponding procedure code must accompany a Z code to describe any procedure performed
Code Z20 indicates what
contact with, and suspected exposure to, cummunicalbe diseases. these codes are for patients who do not show sign or symptom of a disease but are suspected to have been exposed by close personal contact.
status codes indicate
that a patient is either a carrier of a diseae or has the sequelae or residual of a past disease or condition
residual
that which is left behind
sequela
a condition that follows an illness
pressure ulcers are graded how
reported based on the depth of ulcer and categorized in stages
stage 1
erythema - redness of skin
stage 2
partial loss of skin-epidermis or dermis
stage 3
full thickness loss of skin-up to but not through fascia
stage 4
full thickness loss-extensive destruction and necrosis
acute and chronic conditions
same condition is described as both acute(subacute) and chronic, and separate subentries exist in the alphabetic index at the same indentation level, code both and sequence the acute first
sequela also know as what
late effects - after the acute phase of an illness or injury has terminated
combination coding is
when one code fully describes the conditions and/or manifestations
multiple coding is
when it takes more than one code to fully describe the condition, circumstance, or manifestation, and then sequencing of multiple codes is considered
diagnosis of sepsis code how
assign the appropriate code for the underlying systemic infection, if the type of infection or causal organism is not further specified assign code A41.9, sepsis unspecified organism
diagnois of sever sepsis/septic shock code how
systemic infection should be sequenced first followed by code R65.21, any additional codes for the other acute organ dysfunction
R65.2 sever sepsis/shock can never be what
assigned as a principal diagnosis
R65.2 sever sepsis should what
not be assigned unless sever sepsis or an associated acute organ dysfunction is documented
severe sepsis requires what 2 codes
first a code for the underlying systemic infection, followed by a code from subcategory R65.2 sever sepsis
outer layer of skin
dermis
second layer of skin holding blood vessels, nerve endings, sweat glands, and hair follicles
epidermis
tissue below dermis, primarily fat cells that insulate the body
subcutaneous
incision and drainage
to cut and withdrw fluid
abscess
localized collection of pus that will result in the disintergration of tissue over time
cyst
closed sac containing matter or fluid
cleansing of or removing dead tissue from a wound
debridment
horizontal or transverse removal of dermal or epidermal lesions, without full-thickness excision
paring
removal of a small piece of living tissue for diagnostic purposes
biopsy
removal of thin layers of skin by peeling or scraping
shaving
excision
full-thickness removal of a lesion that may include simple closure
benign
not progressive or recurrent
malignant
used to describe a cancerous tumor that grows worse over time
pertains to suturing a wound
repair
transplantation of tissue to repair a defect
skin graft
piece of skin for grafting that is still partially attached to the original blood supply and is used to cover an adjacent wound area
tissue transfer
killing of tissue, possibly by elctrocautery laser, chemical, or other mans
destruction
cryosurgery
destruction of lesions using extreme cold
Tumor on a pedicle that bleeds easily and may become malignant
polyp
Inspection of body organs or cavities using a lighted scope that may be placed through an existing opening or though a small incision
endoscopy
Cavities within the nasal bones
sinuses
maxillary sinus
antrum
Cutting through the antrum wall to make an opening in the sinus
antrotomy
Inspection of the bronchial tree using a bronchoscope
bronchoscopy
Surgical puncture of the thoracic cavity, usually using a needle, to remove fluids
thoracentesis
Surgical incision into the thoracic cavity
thoracotomy
Cutting into the thoracic cavity to allow for enlargement of the heart or for drainage
thoracostomy
Use of a lighted endoscope to view the pleural spaces and thoracic cavity or perform surgical procedures
thoracoscopy
Excision of a lobe of the lung
lobectomy
Covering of the lungs and thoracic cavity that is moistened with serous fluid to reduce friction during respiratory movements of the lungs
pleura
Removal of blockage (embolism) from vessels
embolectomy
What is the name of the item that is placed into the hole in a nasal septum perforation as a repair without surgical grafting?
nasal button
What is the name of the surgical procedure for the reshaping of the nose?
rhinoplasty
What is the name of the surgical procedure for the rearrangement of the nasal septum often used in patients with a deviated septum?
septoplasty
This term means destruction by removing, usually by vaporization, chipping, or other erosive process such as laser or cutting:
ablation
Which approach of treating nasal hemorrhage is most difficult to control, posterior or anterior?
posterior
What term describes washing out an organ?
lavage
What are the two different approaches that can be used to perform a tracheostomy?
transtracheal
cricothyroid
If a surgeon performs a thoracotomy procedure and at the end of the procedure inserts a chest tube for drainage, do you report the insertion of the tube separately? Why?
No, the chest tube is bundled into thoracotomy codes
If bilateral destruction of maxillary sinuses is performed, what modifier would you use?
-50
Removal of two lobes of a lung is termed a(n)
bilobectomy
manifestation
sign of a disease
