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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.)
Main term- Abdominal Pain
Sub term- General
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.)
The importance of starting with alphabetic index is the ease of navigation,
the broad overview making it easier to get a general idea of the possible
codes and provides directive codes; preliminary codes that guide coders to
the correct final code. The tabular list needs to be used because it provides
detailed information it follows a hierarchical structure which helps coders
understand the relationships as well as its used to confirm a code.
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.)
Personal history and Family history
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?
The term that would be 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.)
for encounters for circumstances other than a disease or injury
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.)
1.
Detailed medical record
2.
Understanding of coding guidelines
7.
What is the purpose of the abbreviation NEC?
What is the purpose of the
abbreviation NOS?
(2 parts to the answer.)
NEC- used to categorize data or information that does not fit into existing
categories.
NOS- used where there is insufficient information to make a more specific -
8.
What are the 3 types of Instructional Notes indicated in your Lesson
Content reading assignment?
1.
Clarification notes
2.
Directional notes
3.
Additional 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.
L04.9
13.
Difficulty in walking, NEC.
R26.2
14.
An encounter for an examination for administrative purposes NEC.
Z02.9
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