Ch 12: Review Test Flashcards

Diagnostic Coding (43 cards)

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Diagnosis codes in the outdated ICD-9-CM system consisted of ____ digits or characters?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

25
What is the main term for "acute depressive reaction"?
Reaction
26
When a term has many modifiers that might be listed beneath more than one term; what cross-reference is used?
See also
27
In most ICD-10-CM manuals, main terms in the index appear in ____?
Bold type
28
What is the "placeholder character" in ICD-10-CM?
The letter "x"
29
In ICD, rules and guidelines used in coding are commonly referred to as what?
Conventions
30
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
Bullet
31
NEC in the ICD-10-CM system represents what?
Not elsewhere classified
32
In ICD-10, when a code appears with a Type 1 Excludes note, it means what?
Not coded here
33
In medicine, ____ is a sign or symptom of a disease
A manifestation
34
A ____ code is a single code used to classify two diagnosis with an associated secondary process (manifestation)
Combination
35
In medicine, the study of the form and structure of organisms and their specific structural features is called ____?
Morphology
36
A code listed next to a main term in the ICD-10-CM Index is referred to as a ____?
Default code
37
Sequelae are the ____ or injury or illness
Late effects
38
Which character in an ICD-10-CM code indicates laterality for bilateral sites?
The last character in a six-character code
39
The coder should always begin the search for the correct code assignment in the ____?
Alphabetic Index
40
Under HIPAA, a ____ is any set of codes used for encoding data elements, such as tables of terms, medical concepts, or medical diagnosis codes
Code set
41
What must be coded if a patient's condition has not been specifically diagnosed?
Signs or symptoms
42
How should you code a patient that has both scarlet fever and strep throat?
Two separate codes must be used
43
Identify what must be coded first if a patient's diagnosis is "diabetic ulcer of the heel"
Diabetes