johnsmith_module1worksheet_10082023

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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.) The main term is pain. The sub term is abdominal. The next sub-term would be 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 reason why it is important to start with the Alphabetic Index so it can help the coder determine which section we need to go to in the Tabular List. The reason why a coder needs to go to the Tabular list with the “directive” code from the Alphabetic Index is to make sure they get the most accurate and specific code. The Alphabetic Index does not always provide the full code so the coder needs to go to the Tabular List to get the most specific code that can be up to the 7 th character if applicable and we would only receive that information in the Tabular List. 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.) The two types of history a coder chooses from based on the documentation given is personal and family history codes. 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? 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.) The two reasons a coder may use a z code is either as first-listed like a principal diagnosis or secondary code depending of the circumstances of the encounter.

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.) The two key points that are essential for accurate and most specific coding to develop this skill is using instructional notes and abbreviations found in the Tabular List to ensure accurate coding and also utilizing Chapter Specific Coding Guidelines to ensure that you have the most accurate code in the correct sequence of codes. 7. What is the purpose of the abbreviation NEC? What is the purpose of the abbreviation NOS? (2 parts to the answer.) NEC abbreviation stands for Not elsewhere classifiable. In the Tabular List it represents “other specified” when a code specific code is not available for a condition. NEC abbreviation stands for Not otherwise specified which is equivalent of unspecified. 8. What are the 3 types of Instructional Notes indicated in your Lesson Content reading assignment? (I am very confused on where to find these notes – Is it after the coding guidelines in the beginning of the chapter?) The 3 types of Instructional Notes is Includes highlighted in pink, excluded notes which has two types that will state “Excludes1” and “Excludes2” highlighted in blue. THE QUESTIONS 9-14 CONTAIN DOCUMENTATION TO CODE. 9. Sinus Tachycardia NOS R00.0

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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. Z02.9