BBELLE_Module 01 Assignment - Main Term and Coding Conventions_120324 (1)

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Rasmussen College *

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Mechanical Engineering

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Feb 20, 2024

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MODULE 01 MAIN TERM AND CODING CONVENTIONS WORKSHEET Before answering the questions, you will need to do the following: ● Read the Lesson Content in your Module 01 course for both Main Terms and Coding Conventions. The questions and coding will be based in knowing this information. ● Look up Coding Conventions in your Code Book at the front of the physical code book to gain further understanding of Abbreviations and Instructional notes as these will be very important in accurate coding. ● Further details regarding Main Term and Coding Conventions are also available in your E-textbook for ICD 10 CM coding. About the questions: ● The first 8 questions are short answers based on the Lesson Content reading for both Main Term and Coding Conventions. Some questions have two parts to answer. ● Questions 9-14 require coding. You will need to use main terms for the Alphabetic Index first and then use Instructional Notes and Abbreviations found in the Tabular List to find the most accurate and specific code. ● A reminder from your Coding Foundations course that you use main terms and sub terms when finding the “directive” code in the Alphabetic Index to locate the most accurate and most specific code in the Tabular List. The “directive” code gives you the most efficient way to look up the code in the Tabular List and then use Instructional Notes, Abbreviations, and Coding Guidelines to choose the most accurate and specific code. QUESTIONS 1-8 ARE SHORT ANSWER. 1. Give the main term and then the sub term for the coding documentation “General Abdominal Pain”. (2 parts to the answer.) 1.1. Main Term: Pain 1.2. Sub Term: Abdominal

2. State why starting with the Alphabetic Index is important and why a coder needs to then go to the Tabular List with the “directive” code from the Alphabetic. (2 parts to the answer.) 2.1. Starting with the alphabetic index is important because it contains the main term in a diagnosis which then will refer you to the tabular list. 2.2. A coder next needs to use the tabular list for when a diagnosis requires an additional code to describe the disease. Also guiding the coder to the correct sequencing of the codes. 3. When using a Z code to indicate a “history of” in coding, what two types of history does a coder choose from based on the documentation? (2 parts to the answer.) 3.1. Personal 3.2. Family 4. When documentation indicates “hospice”, what is the term that an ICD 10 CM coder would look for instead of “hospice” in the Alphabetic Index? 4.1. Palliative Care 5. According to the Chapter 21 Chapter Specific Guidelines, what are the two reasons a coder would use a Z code? (2 parts to the answer.) 5.1. For encounters for circumstances other than diseases or injuries 5.2. To indicate a history of any risk factors 6. What are the two key items essential for accurate and most specific coding when developing the skill of ICD 10 CM coding? (2 parts to the answer.) 6.1. Coding Abbreviations 6.2. Instructional Notes 7. What is the purpose of the abbreviation NEC? What is the purpose of the abbreviation NOS? (2 parts to the answer.) 7.1. NEC directs the coder to look for a code in the Tabular List that is “other specified.”

7.2. NOS directs the coder to look for a code in the Tabular List that is “unspecified.” Reference: https://learning.rasmussen.edu/ultra/courses/_147847_1/outline/edit/document/_15358402_1?courseId=_147847_1&view=content 8. What are the 3 types of Instructional Notes indicated in your Lesson Content reading assignment? 8.1. Inclusion Terms 8.2. Includes Notes 8.3. Excludes 1 Notes THE QUESTIONS 9-14 CONTAIN DOCUMENTATION TO CODE. 9. Sinus Tachycardia NOS R00.0 10. Transient dyspnea identified as tachypnea that is attributed to a newborn/neonatal. P22.1- 11. Encounter for immunization without a physical examination. Z23 12. Enlarged lymph nodes documented as lymphadenitis NOS. I88.9 13. Difficulty in walking, NEC. R26.2 14. An encounter for an examination for administrative purposes NEC. Z02.89

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