Ch 12: Review Test Flashcards

Diagnostic Coding

1
Q

A recognized process of transforming descriptions of a patient’s disease process, disorder, or injury into universal numerical or alphanumerical formats is referred to as what?

A

Coding

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2
Q

The reason (sore throat or chest pain) that brings a patient to the healthcare facility is commonly referred to as a(n) ____?

A

Diagnosis

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3
Q

In what year was the first ICD system (ICD-1) put into use?

A

1900

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4
Q

Diagnosis codes in the outdated ICD-9-CM system consisted of ____ digits or characters?

A

3 to 5

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5
Q

Diagnosis codes in the ICD-10-CM system consist of how many digits or characters?

A

3 to 7

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6
Q

The Alphabetic Index in ICD-10 lists all diagnostic terms in what order?

A

Alphabetic order

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7
Q

Part III (Tabular List of Diseases and Injuries) of the ICD-10-CM coding manual is composed of ____ chapters?

A

21

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8
Q

What are three common uses of coding?

A
  • Setting health policy
  • Monitoring resource utilization
  • Preventing healthcare fraud and abuse
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9
Q

What are three valid reasons for converting to ICD-10-CM?

A
  • Lack of specificity in ICD-9 codes
  • Lack of available code numbers in ICD-9
  • ICD-10-CM uses full code titles, reflecting advances in medical technology
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10
Q

In the current diagnostic coding system, what is the manual used for coding inpatient procedures?

A

ICD-10-PCS

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11
Q

Where are diagnosis codes in ICD-10-CM used?

A
  • All physicians’ offices

- Outpatient clinics

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12
Q

In fracture care, a seventh character A indicates what?

A

An initial encounter

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13
Q

After the diagnosis has been determined, the ____ in the diagnosis should be identified

A

Main term or Lead term

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14
Q

When diseases, procedures, or syndromes are named after the individual who discovered or first used them, they are commonly referred to as what?

A

Eponyms

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15
Q

What is the main term in the diagnosis of premature atrial contraction (PAC)?

A

Premature

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16
Q

Some categories, mainly those subject to notes linking them with other categories, require multiple indexing steps. To avoid repeating multiple steps for each of the additional terms involved, a ____ is used.

A

Cross-reference

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17
Q

After the provisional code is located in the ____, the coder should verify the code by locating it in the ____ to ensure that the diagnosis has been coded to the optimal specificity

A

Alphabetic Index / Tabular List

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18
Q

Codes are arranged in the Tabular and divided into chapters based on ____

A
  • Anatomical site
  • Body system
  • Etiology
19
Q

In ICD-10 diagnostic codes, the letter “x” means what?

A
  • Allows for future expansion of the code

- Is used to fill out empty characters when a code contains fewer than six characters and a seventh character applies

20
Q

How is the Index to Diseases in the ICD-10-CM coding manual organized?

A

Alphabetically by main terms

21
Q

What do essential modifiers describe?

A
  • Various anatomical sites
  • The cause or origin of a disease or condition
  • Clinical types
22
Q

Terms enclosed in parentheses after main terms are called what?

A

Nonessential modifiers

23
Q

If a patient’s condition has not been specifically diagnosed, the health insurance professional must code what?

A

Signs or symptoms

24
Q

The ____ code represents the condition that is most commonly associated with the main term or is the unspecified code for the condition

A

Default

25
Q

What is the main term for “acute depressive reaction”?

A

Reaction

26
Q

When a term has many modifiers that might be listed beneath more than one term; what cross-reference is used?

A

See also

27
Q

In most ICD-10-CM manuals, main terms in the index appear in ____?

A

Bold type

28
Q

What is the “placeholder character” in ICD-10-CM?

A

The letter “x”

29
Q

In ICD, rules and guidelines used in coding are commonly referred to as what?

A

Conventions

30
Q

Identify the symbol that typically is used in the Tabular List when an addition digit (or digits) is needed to code a diagnosis to its greatest specificity

A

Bullet

31
Q

NEC in the ICD-10-CM system represents what?

A

Not elsewhere classified

32
Q

In ICD-10, when a code appears with a Type 1 Excludes note, it means what?

A

Not coded here

33
Q

In medicine, ____ is a sign or symptom of a disease

A

A manifestation

34
Q

A ____ code is a single code used to classify two diagnosis with an associated secondary process (manifestation)

A

Combination

35
Q

In medicine, the study of the form and structure of organisms and their specific structural features is called ____?

A

Morphology

36
Q

A code listed next to a main term in the ICD-10-CM Index is referred to as a ____?

A

Default code

37
Q

Sequelae are the ____ or injury or illness

A

Late effects

38
Q

Which character in an ICD-10-CM code indicates laterality for bilateral sites?

A

The last character in a six-character code

39
Q

The coder should always begin the search for the correct code assignment in the ____?

A

Alphabetic Index

40
Q

Under HIPAA, a ____ is any set of codes used for encoding data elements, such as tables of terms, medical concepts, or medical diagnosis codes

A

Code set

41
Q

What must be coded if a patient’s condition has not been specifically diagnosed?

A

Signs or symptoms

42
Q

How should you code a patient that has both scarlet fever and strep throat?

A

Two separate codes must be used

43
Q

Identify what must be coded first if a patient’s diagnosis is “diabetic ulcer of the heel”

A

Diabetes