MedicalCodingUnit1StudyGuide
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School
Purdue Global University *
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Course
HI253
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
8
Uploaded by MinisterKookabura3480
What code explains why
the individual came to see the physician and support the physician's decision about what procedures to provide?
Diagnosis Code
Statistical _blank _ of the data provided by codes can help to write public health policies that will best address areas of concern for the health of our nation.
Analysis
Who are the three parties involved in virtually every encounter?
HCP (1
ST
), Patient (2
nd
), Insurance Company (3
rd
)
Computer programs can easily and quickly organize _blank _ (the codes) to identify the largest
patient population's diagnoses and the most frequently provided treatments and services.
Data
The purpose of using health care coding languages is to enable the _blank _ of information, in a specific and efficient way, between all those involved in health care.
Sharing
In the Alphabetic Index of ICD-10-CM, the diagnostic descriptions are listed by
Condition
Eponym
By requiring medical necessity, it ensures that health care providers are:
not giving injections without a good medical reason
not performing tests without a good medical reason
What is the Alphabetic Index in the ICD-10-CM code book also known as?
Index to Diseases and Injuries
What are some of the uses that research organizations and government agencies use statistical data from codes?
identifying research areas
developing programs
allocating funds
The Tabular List of Diseases and Injuries includes:
coding notations
coding symbols
The process of paying for health care services after they have been provided is referred to as _blank _.
Reimbursement
How many characters would a valid ICD-10-CM code consist of?
7 alphanumeric characters
3 alphanumeric characters
What must administrators and managers ensure are used in the most efficient and effective manner whether in one-physician offices or large hospitals?
Resources
For coding purposes, acupuncture would be considered a
Treatment
International Classification of Diseases--10th Revision--Clinical Modification is used to report:
why the patient was seen.
Which of the following code sets are used to translate health care procedures, services, and treatments?
CPT
ICD-10-PCS
HCPCS Level II
Diagnostic descriptions in the alphabetic index of ICD-10-CM are listed by:
eponym
Condition
Which of the following is true about CPT codes?
CPT codes can report a physician discussion with a patient about test results.
CPT codes can report procedures performed by a physician at any location.
CPT codes can report a contribution by an outpatient facility for sterile procedure.
After locating a code in the Alphabetic Index, the next coding step is to:
look up the code in the Tabular List of Diseases and Injuries
ICD-10-PCS is used to code for:
inpatient visits
What is the appropriate location for the period between code characters?
Between third and fourth characters
CPT codes are also known as:
HCPCS Level I code
For coding purposes, the surgical removal of a mole would be considered a:
procedure
Dental services are coded using which code set?
HCPCS Level II
Can report codes for the administration of anesthesia:
Coder
CPT codes are used to report contributions made by:
physician's offices.
ambulatory surgical centers.
outpatient facilities.
emergency departments of hospitals.
ICD-10-PCS codes are made up of:
7 alphanumeric characters
Which of the following are included in the Healthcare Common Procedure Coding System?
HCPCS Level II
CPT
Which of the following would be coded using a HCPCS Level II code?
Wheelchair
Prosthetic leg
Ambulance transport
Which of the following patient encounters might be assigned that is NOT
actually a procedure, service, or treatment?
2
nd
Opinion
Is identifying the key words or terms needed to determine the accurate code:
Abstracting
is an exact science; it involves changing information from one language to another:
Interpreting Many diagnostic statements are made up of _blank _ words, with each providing additional information:
Multiple
This source documentation is written by the admitting physician and explains the background and current issues used to make the decision to admit the patient into the hospital:
H&P
When abstracting the documentation, you will need to identify signs and symptoms that are already part of the description of a(n) _blank _ diagnosis:
Confirmed
In abstracting, the procedures or services that occurred are known as the _blank _.
What
The cause-and-effect relationship between the two conditions must be documented by the physicians and supported by medical research to be coded as a _blank _.
Manifestation
When might a diagnosis code be assigned that explains why the patient was seen but is not a current health condition or injury?
Screenings
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Routine or administrative exams
Preventive care
When two conditions are present at the same time but there is no documented cause-and-
effect relationship, they are known as _blank _.
co-morbidities
Diagnosis codes, for reimbursement or statistical purposes, will only report _blank _ addressed by the provider during a specific encounter and not the patient's entire health history.
Conditions
The word that identifies the disease, illness, condition, or primary reason for the visit is also known as the _blank _ term.
Main
A sequela is the residual impact of a condition that may need the attention of a physician:
previous
The _blank _ + the symptom = the diagnosis.
Sign
The Index to External Causes is found _blank _ the Alphabetic Index and the Tabular List.
Between
What is also known as a late effect?
Sequela
When abstracting information regarding a patient's injury, you should identify which of the following to determine external causes?
The how and where
A procedural term can be a _blank _ term identifying both the action taken and the anatomical site on which the action was performed.
Combination
To select the best, most accurate code(s) a coder should base the selection on:
documentation.
Official Guidelines.
There are _blank _ specific actions that you should take as part of the coding process.
6
Once you read the documentation, you should reread and identify the main words regarding the _blank _ and _blank _ of the encounter:
why; what
Which of the following are acceptable places to confirm a code in the CPT or ICD-10 books?
Main Section
Tabular List
Tables
What is used to review any diagnosis coding rules with which you must comply?
Official Guidelines
When coding a procedure, for whom might you be reporting?
Inpatient facility
Physician
Outpatient facility
Where can you find conventions that offer tips and hints in selecting the correct code?
ICD-10-CM Tabular List
CPT Main Section
With so many code sets and codes, the process to get from _blank _ to _blank _ is more complicated than simply finding a word here and a code there.
documentation; code
When abstracting information regarding a patient's injury, you should identify which of the following to determine external causes?
The how and where.
Select the title used for the ICD-10-CM Guidelines:
ICD-10-CM Official Guidelines for Coding and Reporting
Which of the following is a term seen in the ICD-10-CM Alphabetic Index?
Shock
The book includes official guidelines within the sections, subsections, with advice and direction for accurate coding or just those procedures, services, and treatments:
CPT Which of the following uses alpha numeric or numeric order for code selection?
ICD-10-CM Tabular List
CPT Main Section
ICD-10-PCS Tables
Where are the guidelines located in the ICD-10-CM book?
Front of Book.
In an outpatient setting, there must be a _blank _ and a _blank _ to support medical necessity:
diagnosis code; procedure code
You cannot report a code from the Alphabetic Index until you have confirmed it is correct and complete by using which one of the following code books?
ICD-10-PCS's Tables section
ICD-10-CM's Tabular List
CPT's Main Section
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