Deck 4: Basic Steps of Coding

Question 1

The main terms usually are nouns and/or disease conditions.

Answer 1

True

Question 2

When evaluating an ER record, a coder should look for the ____.

A)diagnosis
B)chief complaint
C)probable diagnosis
D)differential diagnosis

Answer 2

B

Question 3

The main term is ____.

A)always identified in italics
B)a review of the patient's hospital course
C)a term identifying disease conditions or injuries
D)a word found in parentheses that enclose explanatory information that does NOT affect the code

Answer 3

C

Question 4

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
The reason, in the patient's own words, for coming to the hospital

Question 5

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Question 6

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
When a patient displays a symptom that could represent a variety of diagnoses

Question 7

The first step in coding the principal diagnosis is to ____.

A)identify the diagnosis and the principal procedure
B)identify main term(s) in the Alphabetic Index
C)review the medical record
D)review any subterms under the main term in the Index

Question 8

To be sure you have the correct diagnosis code, it is very important to go to the Alphabetic Index first and then to the Tabular List.

Question 9

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Have no effect on the main term

Question 10

Which of the following is a basic step in coding?

A)Review the medical record.
B)Identify main term(s) in the Alphabetic Index.
C)Assign codes to the highest level of specificity by verifying in the Tabular List.
D)All of the options are correct.

Question 11

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

Question 12

The admitting diagnosis is usually a sign or a symptom.

Question 13

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Question 14

The main term in "aplastic anemia" is ____.

A)anemia
B)aplasia
C)aplastic
D)none of the above

Question 15

A coder must always remember that, after a term is located in the Alphabetic Index, the code must be verified in the Tabular List.

Question 16

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Synopsis of the events of a patient's hospital encounter

Question 17

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?

A)Coders may not have a discharge summary at the time of coding.
B)If the patient is in the hospital for a long stay, the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay.
C)Physicians list diagnoses that are not currently being treated and are only in the patient's history.
D)All of the options are correct.

Question 18

In the discharge summary, a physician lists the __________ that were evaluated and treated and any procedures that were performed.

Question 19

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Emergency Room

Question 20

The __________, if available, is the first step in the process of record review for code selection.

Question 21

What is the subterm in "esophageal reflux"?

Question 22

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Provides advice on how to correctly code specific diagnoses

Question 23

What is the main term in "aspiration pneumonia"?

Question 24

What is the main term in "infantile eczema"?

Question 25

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
A cross-reference instruction in the code book

Question 26

What is the subterm in "infantile eczema"?

Question 27

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
After a code has been selected from the Alphabetic Index, it must be verified in this

Question 28

What is the subterm in "aspiration pneumonia"?

Question 29

What is the main term in "rheumatoid arthritis"?

Question 30

What is the subterm in "rheumatoid arthritis"?

Question 31

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Review the health record

Question 32

What is the main term in "calculus of the ureter"?

Question 33

Match each definition to one of the following items.
a.Tabular List
b.See also
c.Subterms
d.Discharge summary
e.Coding Clinic
f.ER
g.Differential diagnosis
h.Chief complaint
i.The first basic step in coding the principal diagnosis
j.Nonessential modifiers
Modifiers of the main term that have an effect on the appropriate code choice

Question 34

What is the main term in "esophageal reflux"?

Question 35

After a code has been selected from the Alphabetic Index to Diseases, what is the next step?