vocab Flashcards

1
Q

etiology

A

the cause, set of cause, or manner of causation of a disease or condition

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2
Q

manifestation

A

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.

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3
Q

7th characters and place holder

A

codes less than 6 characters that require a 7th character a placeholder X is assigned for all character less than 6

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4
Q

7th character A

A

initial encounter - all encounters involving diagnosis and treatment

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5
Q

7th character D

A

subsequent encounter - encounters during the healing phase

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6
Q

7th character S

A

sequela

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7
Q

which diagnosis is used in an outpatient setting first

A

first list diagnosis is used in lieu of principal diagnosis

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8
Q

chapter 21 Z codes are

A

factors influencing health status and cotact with health services Z00-Z99

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9
Q

T/F certain Z codes may ony be used as 1st listed or principal diagnosis

A

true

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10
Q

T/F Z codes indicate a reason for an encounter

A

true

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11
Q

T/F Z codes are not procedure codes

A

true a corresponding procedure code must accompany a Z code to describe any procedure performed

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12
Q

Code Z20 indicates what

A

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.

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13
Q

status codes indicate

A

that a patient is either a carrier of a diseae or has the sequelae or residual of a past disease or condition

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14
Q

residual

A

that which is left behind

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15
Q

sequela

A

a condition that follows an illness

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16
Q

pressure ulcers are graded how

A

reported based on the depth of ulcer and categorized in stages

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17
Q

stage 1

A

erythema - redness of skin

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18
Q

stage 2

A

partial loss of skin-epidermis or dermis

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19
Q

stage 3

A

full thickness loss of skin-up to but not through fascia

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20
Q

stage 4

A

full thickness loss-extensive destruction and necrosis

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21
Q

acute and chronic conditions

A

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

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22
Q

sequela also know as what

A

late effects - after the acute phase of an illness or injury has terminated

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23
Q

combination coding is

A

when one code fully describes the conditions and/or manifestations

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24
Q

multiple coding is

A

when it takes more than one code to fully describe the condition, circumstance, or manifestation, and then sequencing of multiple codes is considered

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25
Q

diagnosis of sepsis code how

A

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

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26
Q

diagnois of sever sepsis/septic shock code how

A

systemic infection should be sequenced first followed by code R65.21, any additional codes for the other acute organ dysfunction

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27
Q

R65.2 sever sepsis/shock can never be what

A

assigned as a principal diagnosis

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28
Q

R65.2 sever sepsis should what

A

not be assigned unless sever sepsis or an associated acute organ dysfunction is documented

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29
Q

severe sepsis requires what 2 codes

A

first a code for the underlying systemic infection, followed by a code from subcategory R65.2 sever sepsis

30
Q

outer layer of skin

A

dermis

31
Q

second layer of skin holding blood vessels, nerve endings, sweat glands, and hair follicles

A

epidermis

32
Q

tissue below dermis, primarily fat cells that insulate the body

A

subcutaneous

33
Q

incision and drainage

A

to cut and withdrw fluid

34
Q

abscess

A

localized collection of pus that will result in the disintergration of tissue over time

35
Q

cyst

A

closed sac containing matter or fluid

36
Q

cleansing of or removing dead tissue from a wound

A

debridment

37
Q

horizontal or transverse removal of dermal or epidermal lesions, without full-thickness excision

A

paring

38
Q

removal of a small piece of living tissue for diagnostic purposes

A

biopsy

39
Q

removal of thin layers of skin by peeling or scraping

A

shaving

40
Q

excision

A

full-thickness removal of a lesion that may include simple closure

41
Q

benign

A

not progressive or recurrent

42
Q

malignant

A

used to describe a cancerous tumor that grows worse over time

43
Q

pertains to suturing a wound

A

repair

44
Q

transplantation of tissue to repair a defect

A

skin graft

45
Q

piece of skin for grafting that is still partially attached to the original blood supply and is used to cover an adjacent wound area

A

tissue transfer

46
Q

killing of tissue, possibly by elctrocautery laser, chemical, or other mans

A

destruction

47
Q

cryosurgery

A

destruction of lesions using extreme cold

48
Q

Tumor on a pedicle that bleeds easily and may become malignant

A

polyp

49
Q

Inspection of body organs or cavities using a lighted scope that may be placed through an existing opening or though a small incision

A

endoscopy

50
Q

Cavities within the nasal bones

A

sinuses

51
Q

maxillary sinus

A

antrum

52
Q

Cutting through the antrum wall to make an opening in the sinus

A

antrotomy

53
Q

Inspection of the bronchial tree using a bronchoscope

A

bronchoscopy

54
Q

Surgical puncture of the thoracic cavity, usually using a needle, to remove fluids

A

thoracentesis

55
Q

Surgical incision into the thoracic cavity

A

thoracotomy

56
Q

Cutting into the thoracic cavity to allow for enlargement of the heart or for drainage

A

thoracostomy

57
Q

Use of a lighted endoscope to view the pleural spaces and thoracic cavity or perform surgical procedures

A

thoracoscopy

58
Q

Excision of a lobe of the lung

A

lobectomy

59
Q

Covering of the lungs and thoracic cavity that is moistened with serous fluid to reduce friction during respiratory movements of the lungs

A

pleura

60
Q

Removal of blockage (embolism) from vessels

A

embolectomy

61
Q

What is the name of the item that is placed into the hole in a nasal septum perforation as a repair without surgical grafting?

A

nasal button

62
Q

What is the name of the surgical procedure for the reshaping of the nose?

A

rhinoplasty

63
Q

What is the name of the surgical procedure for the rearrangement of the nasal septum often used in patients with a deviated septum?

A

septoplasty

64
Q

This term means destruction by removing, usually by vaporization, chipping, or other erosive process such as laser or cutting:

A

ablation

65
Q

Which approach of treating nasal hemorrhage is most difficult to control, posterior or anterior?

A

posterior

66
Q

What term describes washing out an organ?

A

lavage

67
Q

What are the two different approaches that can be used to perform a tracheostomy?

A

transtracheal

cricothyroid

68
Q

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?

A

No, the chest tube is bundled into thoracotomy codes

69
Q

If bilateral destruction of maxillary sinuses is performed, what modifier would you use?

A

-50

70
Q

Removal of two lobes of a lung is termed a(n)

A

bilobectomy

71
Q

manifestation

A

sign of a disease