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MA Final Exam Q's for May 13th > Chp. 18 Review Q's > Flashcards

Chp. 18 Review Q's Flashcards

1
Q

Match the terms World health organization, International classification of diseases, and conventions with their definitions.

A

World Health Organization = Unit of the United Nations devoted to international health problems

International Classification of Diseases = Code set that is based on a system maintained by the World Health Organization of the United Nations; codes are mandated by HIPAA for reporting patients’ diseases, conditions, and signs and symptoms

Conventions = Abbreviations, punctuation, symbols, typefaces, and instructional notes at the beginning of the ICD-9, providing guidelines for using the code set

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2
Q

World Health Organization

A

Unit of the United Nations devoted to international health problems

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3
Q

International Classification of Diseases

A

Code set that is based on a system maintained by the World Health Organization of the United Nations; codes are mandated by HIPAA for reporting patients’ diseases, conditions, and signs and symptoms

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4
Q

Conventions

A

Abbreviations, punctuation, symbols, typefaces, and instructional notes at the beginning of the ICD-9, providing guidelines for using the code set

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5
Q

What edition is the current ICD?

A

10

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6
Q

Patients’ description of their medical problem is called a _________

A

Chief Complaint

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7
Q

A(n) ______ describes the primary condition for which a patient is receiving care.

A

diagnosis

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8
Q

Additional conditions or symptoms that affect a patient’s management are called __________

A

coexisting conditions

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9
Q

One of 2 ways diagnoses are listed in the ICD-9-CM; they appear in alphabetic order with their corresponding diagnosis codes

A

Alphabetic Index

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10
Q

In both ICD-9 and ICD-10, the first 3 digits of the diagnosis code

A

Categories

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11
Q

Breakdown of diagnosis codes by body system or disease; there are 17 chapters in ICD-9 and 21 in ICD-10

A

Chapters

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12
Q

One of 2 ways that diagnoses are listed in the ICD-10; in the Tabular List, the diagnosis codes are listed in numerical order with additional instructions

A

Tabular List

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13
Q

Fourth digits added to many ICD-10 codes, giving further specificity to a diagnosis

A

Subcategories

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14
Q

How is a diagnosis communicated to a third-party payer on a healthcare claim?

A

Diagnosis Code

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15
Q

What does the CM stand for in ICD-10-CM?

A

Clinical Modification

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16
Q

Where are ICD-10 codes available?

A

On CD-ROM

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17
Q

When is the chief complaint documented?

A

At each visit

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18
Q

What does the acronym WHO stand for?

A

World Health Organization

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19
Q

Who may establish a diagnosis that describes the primary condition for which a patient is receiving care?

A

Physician

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20
Q

The ICD codes are updated every year on ____

A

October 1st

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21
Q

Coexisting conditions that currently affect a patient’s condition or treatment must be ___

A

reported to insurance carrier.

coded.

noted in the chart.

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22
Q

The diagnoses listed on a healthcare claim form should prove _______

A

medical necessity

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23
Q

What is another word for patient morbidity?

A

Sickness

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24
Q

The diagnosis codes used in the United States are found in the ___

A

ICD-CM-10

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25
Q

ICD-10 codes can be used to ____

A

study of healthcare costs.

planning future healthcare needs.

evaluate patient use of healthcare facilities.

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26
Q

The ICD-10 code set is based on a system maintained by the ______

A

World Health Organization (WHO)

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27
Q

The ICD-10 Tabular List incorporates how many chapters?

A

21

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28
Q

______ mandates the use of ICD-10-CM codes in the healthcare industry.

A

HIPAA

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29
Q

What was the ICD-10-CM originally created to classify?

A 
Patient mortality (death)
Patient morbidity (sickness)
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30
Q

The number of characters in an ICD-10 code ranges from 3 to ______.

A

7

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31
Q

Today, ICD-10 codes are increasingly important and used for which of the following reasons?

A

Prediction of healthcare trends

Facilitation of payment for medical services

Research regarding quality of healthcare

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32
Q

The first step in coding with ICD-10 begins with the _____

A

Alphabetic Index

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33
Q

The ICD-10 uses a(n) ______ to hold a place for future expansion of the codes’ specificity.

A

X

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34
Q

A code in which 2 diagnoses are included in 1 code is known as a ____

A

Combination code

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35
Q

Which of the following has the correct format for an ICD-10 code?

A

D05.01

(ICD-10 codes ALWAYS begin with an alphabetical letter)

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36
Q

Which part of ICD-10-CM is Volume 1?

A

Tabular List

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37
Q

The ‘X’ in an ICD-10 codes designates ______.

A

a placeholder.

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38
Q

Most of the NOS codes end with the number ______.

A

9

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39
Q

Which of the following are examples of where a combination code may be used?

A

Diagnosis with an associated complication

Diagnosis with an associated manifestation

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40
Q

The abbreviation NEC means ____

A

not elsewhere classified.

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41
Q

The Alphabetic Index is Volume ______ of the ICD-10-CM.

A

Volume 2.

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42
Q

Which of the following are found in the conventions of the ICD-10?

A

Punctuation

Abbreviations

Instructional notes

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43
Q

How are “[ ] brackets” used as a convention in the Tabular List?

A

Around synonyms

Around explanations

Around alternative wordings

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44
Q

The abbreviation NOS means

A

Not otherwise specified

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45
Q

When brackets in the Alpha Index convention is used, the code in the brackets is the ____

A

secondary code

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46
Q

How are the convention “( ) parentheses” used?

A

Around descriptions that do not affect the code

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47
Q

Which convention is used when the ICD-10 does not provide a code specific enough for the patient’s condition?

A

NEC (not elsewhere classified)

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48
Q

______ are used in the Tabular List after an incomplete term that needs one of the terms that follow to make it assignable to a given category.

A

: Colons

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49
Q

______ are used around synonyms, alternative wordings, or explanations as possible aides to help you pick out the right code.

A

[ ] Brackets

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50
Q

Which convention appears in the Alphabetic Index to indicate that two codes will be required to completely code the diagnosis?

A

[ ] Brackets

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51
Q

Parentheses ‘( )’ are used around descriptions that are ____

A

nonessential terms.

supplementary terms.

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52
Q

Which of the following are notes that indicate that the following entries define the content of a preceding entry?

A

Includes

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53
Q

How is the “: Colon” convention used in ICD-10?

A

After an incomplete term that needs another term to make it assignable

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54
Q

There are ______ types of excludes codes.

A

two

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55
Q

The additional code is always listed ______

A

after the primary code

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56
Q

What does an includes notation look like?

A

Boxed

Capital Letters

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57
Q

What does the Excludes notation look like?

A

Italicized

Boxed

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58
Q

______ are used around synonyms, alternative wordings, or explanations as possible aides to help you pick out the right code.

A

[ ] Brackets

59
Q

How should a code with the “Code first underlying disease” notation be used?

A

It may not be used as the first code.

It should follow the primary diagnosis code.

60
Q

Which of the following conventions indicates that an added code should be utilized, if available?

A

Use additional code

61
Q

Where is italicized typeface used as a convention in the Tabular List?

A

Exclusion notes

Secondary diagnoses

62
Q

Which words in the Alphabetic Index refer you to a different “main term” for the condition?

A

See Condition

63
Q

Which of the following are notes that indicate that the following entries define the content of a preceding entry?

A

Includes

64
Q

The Alphabetic Index is categorized by ____

A

conditions.

65
Q

There are ______ types of excludes codes.

A

two

66
Q

What term should you look up when coding a wrist fracture?

A

Fracture

67
Q

The instruction that appears when a category is not to be used as the primary diagnosis is ____

A

Code first underlying disease.

68
Q

How is bold typeface used as a convention in the Tabular List?

A

For titles

For codes

69
Q

What convention will you see if you look up the term cervix in the Alphabetic Index for a patient who has a diagnosis of cervical inflammation?

A

See condition

70
Q

Put the steps for assigning the correct code in order, with the first step on top.

A
  1. Look up the main term that describes pt’s. condition in Alphabetic Index
  2. Find the appropriate sub term according to site or source of disease if necessary.
  3. Cross-reference the code from the Alphabetic Index with the Tabular List.
  4. Choose the appropriate fourth through seventh digit if necessary.
71
Q

To look up a diagnosis code in the Alphabetic Index, first think about ___

A

the problem.

72
Q

Which types of terms are placed in parentheses?

A

Nonessential

73
Q

How should a code with the “Code first underlying disease” notation be used?

A

It may not be used as the first code.

It should follow the primary diagnosis code.

74
Q

Where is italicized typeface used as a convention in the Tabular List?

A

Secondary diagnoses

Exclusion notes

75
Q

Which words in the Alphabetic Index refer you to a different “main term” for the condition?

A

See condition

76
Q

When using the Alphabetic Index, what should be considered first?

A

The problem

77
Q

Which of the following can assist you in choosing the correct code, but it is not mandatory that they be present within the code description?

A

Nonessential terms

78
Q

If the term ‘See’ appears after a main term,

A

you must look up the term that follows the word.

79
Q

The instruction that appears when a category is not to be used as the primary diagnosis is

A

Code first underlying disease.

80
Q

The Tabular List for ICD-10 consists of ______ chapters of disease descriptions and codes.

A

21

81
Q

What do ICD-10-CM diagnosis codes look like?

A

3 to 7 alphanumeric digits

82
Q

Where can you find the diagnosis if your provider uses a SOAP note?

A

In the assessment

83
Q

Which words appear after a term to indicate a cross-reference?

A

See

See also

84
Q

In addition to chapters for each body system, ICD-10, also includes a chapter for

A

injuries related to poisonings

85
Q

A long-standing condition is known as

A

chronic.

86
Q

What is the term for the 3-character category?

A

Rubric

87
Q

Who’s responsibility can it be to locate the most appropriate code from the encounter and is supported in the medical record?

A

Coder

Medical Assistant

88
Q

What will occur when one code does not fully describe the patient’s diagnosis?

A

Multiple coding

89
Q

Which of the following terms flag a diagnosis as being uncertain?

A

Suspected

Probable

Rule out

90
Q

A condition of sudden onset or a more long-standing condition that has suddenly worsened is known as a(n)

A

acute condition

91
Q

The ______ diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

A

principal

92
Q

Other conditions that are also affecting a patient at the time of a visit are known as ______ diagnoses.

A

secondary

93
Q

Multiple coding often occurs when

A

a disease or condition is the result of another condition.

94
Q

There are over 700 DRGs. What are they?

A

Diagnosis-related groups, which based on four elements for inpatient coding.

95
Q

In outpatient coding, when should the symptoms that lead the patient to seek care be coded?

A

When there is an unclear diagnosis

Until an absolute diagnosis is made

96
Q

Outpatient coding uses the ______ diagnosis to describe the main reason for the patient’s visit.

A

primary

97
Q

Another term for secondary diagnosis is

A

subsequent diagnosis.

98
Q

What will occur when one code does not fully describe the patient’s diagnosis?

A

Multiple coding

99
Q

What are the four elements to diagnosis-related groups?

A

Principal diagnosis

Age of the patient

Discharge status of the patient

Procedures performed

100
Q

When a patient is healthy and has no problems a ____ code is used in the outpatient setting.

A

Z

101
Q

Place of occurrence codes are found under what key term?

A

Place

102
Q

Where is the Table of Drugs and Chemicals located in ICD-10?

A

Directly after the Alphabetic Index

103
Q

A accidental poisoning is defined as

A

an accidental overdose.

a wrong substance given or taken.

a drug taken by mistake.

104
Q

What are examples of health status codes?

A

Encounter for vaccination

Encounter for Chemotherapy

105
Q

Which 7th character designates a subsequent encounter?

A

D

106
Q

ICD-10 created ________________ codes for poisonings so that in many cases only one code will be required.

A

combination

107
Q

An assault poisoning is defined as

A

intentionally harmed/poisoned by another person

108
Q

Coding burns typically requires ______ code(s).

A

3 codes (think 3rd degree burns - 3 codes)

109
Q

Which ICD-10 code should be assigned when no definitive diagnosis or manifestation of HIV is present and the patient has an inconclusive serology?

A

R75

110
Q

If a patient’s neoplasm has metastasized and the patient’s treatment is for the secondary site, the secondary neoplasm would be the

A

primary diagnosis.

principal diagnosis.

111
Q

Type ______ diabetes is noninsulin-dependent diabetes.

A

2

112
Q

Coding burns typically requires which of the following codes?

A

Degree of burn

Extent of burn

External cause code for cause of burn

113
Q

Which ICD-10 code should be assigned to a patient who has had a positive serology or culture and has developed an HIV-related illness?

A

B20

114
Q

Chapter ______ of the ICD-10-CM deals with neoplasms.

A

2

115
Q

What factors are included in the combination codes for diabetes in ICD-10?

A

Type of diabetes

Body system affected

Condition affecting anatomical structure

116
Q

Pain that is associated with and is exclusively psychological should be assigned code

A

F45.41

117
Q

Which code is used for a pain diagnosis?

A

G89

118
Q

Which chapter of ICD-10 contains codes for conditions such as hypertension and diseases of the circulatory system?

A

Chapter 9

119
Q

Positive laboratory documentation is ________ in order to code either novel A or H1N1 influenza.

A

not required

120
Q

Chapter ______ of ICD-10-CM deals with diseases of the musculoskeletal system and connective tissue.

A

13

121
Q

Which chapter of ICD-10 deals with mental and behavioral disorders?

A

5

122
Q

Match the terms referring to types of encounters to treat a fracture with their definitions.

A

Initial = Active fracture that is still healing

Subsequent = Follow-up care after the active fracture

Sequela = Care after the injury has healed

123
Q

What body areas are given their own section in ICD-10 and no longer found in the nervous system section?

A

Eyes and ears

124
Q

Match the codes with the stages of chronic kidney disease (CKD).

A

N18.1 = Beginning stage

N18.2 = Mild CKD

N18.3 = Moderate CKD

N18.4 = Severe CKD

N18.6 = End-stage renal disease

125
Q

How many codes are required when hypertension is caused by an underlying condition?

A

2

126
Q

When coding pregnancies in ICD-10, what does the seventh digit specify?

A

Trimester of pregnancy

127
Q

When the provider’s documentation states ______ novel A influenza or H1N1 influenza codes from J09.0 category should be assigned.

A

probable

suspected

128
Q

Which of the following are changes from ICD-9 to ICD-10 in coding for fractures?

A

Mandatory seventh character

Laterality

129
Q

The terms initial, subsequent, and sequela are useful in determining which digit of an ICD-10 code for a fracture?

A

Seventh

130
Q

You should exclusively use codes from Chapter _____ when a patient’s medical record documents that the diagnosis or condition is congenital or chromosomal in nature.

A

17

131
Q

How many stages of chronic kidney disease are provided in ICD-10?

A

4

132
Q

Which chapter of ICD-10 is used to code signs, symptoms, and abnormal clinical and laboratory findings?

A

18

133
Q

Which chapter of ICD-10-CM deals with pregnancy, childbirth, and the puerperium?

A

15

134
Q

The total body area for burn coding is based on the rule of

A

nines

135
Q

Positive laboratory documentation is ________ in order to code either novel A or H1N1 influenza.

A

not required

136
Q

Codes from chapter 20 identify the ______ an accident or injury occurred.

A

where

who

what

when

137
Q

Select all diseases and conditions you would find in Chapter 17 of the ICD-10.

A

Hydrocephalus

Atrial septal defect

Limb malformations and deformities

138
Q

What reasons for healthcare encounters are included in chapter 21?

A

Aftercare

Chemotherapy

139
Q

The codes in Chapter 18 of ICD-10 are used primarily for coding which of the following types of conditions?

A

Transient signs and symptoms at the initial encounter with undetermined cause

Cases without a definitive diagnosis referred elsewhere

140
Q

By which factors are burns classified in ICD-10?

A

Burn agent

Extent of the affected body area

Burn depth

141
Q

When the provider’s documentation states ______ novel A influenza or H1N1 influenza codes from J09.0 category should be assigned.

A

suspected

probable

142
Q

Which chapter in ICD-10 replaces the E codes in ICD-9?

A

20

143
Q

Which chapter of ICD-10 contains codes for factors influencing health status and contact with health services?

A

21

MA Final Exam Q's for May 13th (2 decks)

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