Deck 4: Basic Steps of Coding

Question 1

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

Answer 1

False

Question 2

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

Answer 2

True

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

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 5

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

Question 6

Match the following with the correct term or definition.
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 7

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

Question 8

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

Question 9

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

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

Question 10

The main term in "aplastic anemia" is ____.

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

Question 11

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 12

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

Question 13

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

Question 14

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 15

The admitting diagnosis is usually a sign or a symptom.

Question 16

The main term for procedures in ICD-10-CM is identified by the ____.

A)anatomic site
B)place of incision
C)procedure performed
D)none of the above are correct

Question 17

What is the main term in the procedure "vaginal hysterectomy"?

A)Vaginal
B)Hysterectomy
C)Vaginal hysterectomy
D)None of the above

Question 18

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
D)All of the options are correct

Question 19

Match the following with the correct term or definition.
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 20

When assigning a procedure code in ICD-10-PCS,the coder must first start with the Alphabetic Index.

Question 21

What is the subterm in "aspiration pneumonia"?

Question 22

Match the following with the correct term or definition.
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 23

What is the main purpose of the Alphabetic Index in ICD-10-PCS?

Question 24

What is the subterm in "rheumatoid arthritis"?

Question 25

Match the following with the correct term or definition.
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 26

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

Question 27

What is the subterm in "infantile eczema"?

Question 28

Match the following with the correct term or definition.
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 29

What is the main term in "aspiration pneumonia"?

Question 30

What is the main term in "esophageal reflux"?

Question 31

Match the following with the correct term or definition.
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 32

What is the main term in "infantile eczema"?

Question 33

Match the following with the correct term or definition.
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 34

Match the following with the correct term or definition.
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 35

Match the following with the correct term or definition.
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 36

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

Question 37

What is the subterm in "esophageal reflux"?

Question 38

What is the main term in "rheumatoid arthritis"?

Question 39

Match the following with the correct term or definition.
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
Once a code has been selected from the Alphabetic Index,it must be verified in this