vocab

Question 1

etiology

Answer 1

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

Question 2

manifestation

Answer 2

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.

Question 3

7th characters and place holder

Answer 3

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

Question 4

7th character A

Answer 4

initial encounter - all encounters involving diagnosis and treatment

Question 5

7th character D

Answer 5

subsequent encounter - encounters during the healing phase

Question 6

7th character S

Answer 6

sequela

Question 7

which diagnosis is used in an outpatient setting first

Answer 7

first list diagnosis is used in lieu of principal diagnosis

Question 8

chapter 21 Z codes are

Answer 8

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

Question 9

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

Answer 9

true

Question 10

T/F Z codes indicate a reason for an encounter

Answer 10

true

Question 11

T/F Z codes are not procedure codes

Answer 11

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

Question 12

Code Z20 indicates what

Answer 12

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.

Question 13

status codes indicate

Answer 13

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

Question 14

residual

Answer 14

that which is left behind

Question 15

sequela

Answer 15

a condition that follows an illness

Question 16

pressure ulcers are graded how

Answer 16

reported based on the depth of ulcer and categorized in stages

Question 17

stage 1

Answer 17

erythema - redness of skin

Question 18

stage 2

Answer 18

partial loss of skin-epidermis or dermis

Question 19

stage 3

Answer 19

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

Question 20

stage 4

Answer 20

full thickness loss-extensive destruction and necrosis

Question 21

acute and chronic conditions

Answer 21

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

Question 22

sequela also know as what

Answer 22

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

Question 23

combination coding is

Answer 23

when one code fully describes the conditions and/or manifestations

Question 24

multiple coding is

Answer 24

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

Question 25

diagnosis of sepsis code how

Answer 25

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

Question 26

diagnois of sever sepsis/septic shock code how

Answer 26

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

Question 27

R65.2 sever sepsis/shock can never be what

Answer 27

assigned as a principal diagnosis

Question 28

R65.2 sever sepsis should what

Answer 28

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

Question 29

severe sepsis requires what 2 codes

Answer 29

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

Question 30

outer layer of skin

Answer 30

dermis

Question 31

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

Answer 31

epidermis

Question 32

tissue below dermis, primarily fat cells that insulate the body

Answer 32

subcutaneous

Question 33

incision and drainage

Answer 33

to cut and withdrw fluid

Question 34

abscess

Answer 34

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

Question 35

cyst

Answer 35

closed sac containing matter or fluid

Question 36

cleansing of or removing dead tissue from a wound

Answer 36

debridment

Question 37

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

Answer 37

paring

Question 38

removal of a small piece of living tissue for diagnostic purposes

Answer 38

biopsy

Question 39

removal of thin layers of skin by peeling or scraping

Answer 39

shaving

Question 40

excision

Answer 40

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

Question 41

benign

Answer 41

not progressive or recurrent

Question 42

malignant

Answer 42

used to describe a cancerous tumor that grows worse over time

Question 43

pertains to suturing a wound

Answer 43

repair

Question 44

transplantation of tissue to repair a defect

Answer 44

skin graft

Question 45

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

Answer 45

tissue transfer

Question 46

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

Answer 46

destruction

Question 47

cryosurgery

Answer 47

destruction of lesions using extreme cold

Question 48

Tumor on a pedicle that bleeds easily and may become malignant

Answer 48

polyp

Question 49

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

Answer 49

endoscopy

Question 50

Cavities within the nasal bones

Answer 50

sinuses

Question 51

maxillary sinus

Answer 51

antrum

Question 52

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

Answer 52

antrotomy

Question 53

Inspection of the bronchial tree using a bronchoscope

Answer 53

bronchoscopy

Question 54

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

Answer 54

thoracentesis

Question 55

Surgical incision into the thoracic cavity

Answer 55

thoracotomy

Question 56

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

Answer 56

thoracostomy

Question 57

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

Answer 57

thoracoscopy

Question 58

Excision of a lobe of the lung

Answer 58

lobectomy

Question 59

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

Answer 59

pleura

Question 60

Removal of blockage (embolism) from vessels

Answer 60

embolectomy

Question 61

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

Answer 61

nasal button

Question 62

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

Answer 62

rhinoplasty

Question 63

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

Answer 63

septoplasty

Question 64

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

Answer 64

ablation

Question 65

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

Answer 65

posterior

Question 66

What term describes washing out an organ?

Answer 66

lavage

Question 67

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

Answer 67

transtracheal | cricothyroid

Question 68

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?

Answer 68

No, the chest tube is bundled into thoracotomy codes

Question 69

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

Answer 69

-50

Question 70

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

Answer 70

bilobectomy

Question 71

manifestation

Answer 71

sign of a disease