cbruce_Assignment Main Terms and Coding Conventions_111223

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Rasmussen College, Florida *

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HIM1125

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Mechanical Engineering

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Jan 9, 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.) a. The main term would be “Pain ” and the sub term would be “abdominal” for the location. b. The next sub term would be “generalized ”. 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.)

a. It provides an alphabetical list of terms and their corresponding codes; it also helps determine which section to refer to in the Tabular List for additional information. b. A coder needs to go to the Tabular List with the “directive” code from the Alphabetic Index in order to verify the code selected and to read and be guided by instructional notations that appear in both the Alphabetic Index and 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.) a. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence, and may require monitoring. b. Family history codes are for use when a patient has a family member who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. 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? An ICD 10 CM coder would use the term “Palliative care” instead of “hospice”. 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.) a. To indicate a reason for an encounter that is not related to a disease, injury, or external cause of morbidity. b. To provide additional information about a patient encounter. To indicate a patient’s exposure to a communicable disease, immunization status, or need for follow up care. 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.) a. Having knowledge of the ICD-10-CM coding guidelines and conventions. The guidelines and conventions provide rules and instructions for assigning codes accurately and specifically.

b. Thorough documentation is important. Accurate and specific coding requires thorough documentation that supports the diagnosis and treatment of the patient. 7. What is the purpose of the abbreviation NEC? What is the purpose of the abbreviation NOS? (2 parts to the answer.) a. The purpose of the abbreviation NEC is to indicate that a specific code is not available for a condition, and the Index directs the coder to the “other specified code in the Tabular List. b. The purpose of the abbreviation NOS is to indicate that the documentation does not provide enough information to assign a more specific code, it is the equivalent of “unspecified”. 8. What are the 3 types of Instructional Notes indicated in your Lesson Content reading assignment? a. Inclusion Terms-(Definition, Purpose, Example) b. Includes Notes-(Definition, Purpose, Example) c. Excludes 1 Notes-(Definition, Purpose, Example) 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

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