rad2329's version from 2015-04-22 22:19

Section 1

Question Answer
What are the three basic steps for locating codes to be assigned?Locate the main term in the Alphabetic Index. (Search for subterms, notes, or cross-references) - Verify the code number in the Tabular List - Assign the verified code or codes.
The Alphabetic Index of Diseases and Injuries in volume 2 includes what?Mainterms (diseases, conditions, or injuries), and subterms (site, type, or etiology).
The Tablular List and Alphabetic Index of Procedures in volume 3 contains what?The Alphabetic Index and the Tabular List for surgery and procedures.
What is the first step in coding?Locate the main term in the Alphabetic Index.
In volume 2 (the Alphabetic Index) what is considered to be the main term?The condition, usually expressed as a "noun".
If you can not locate the main term in the Alphabetic Index what should the coder do?Consider a synonym, eponym or other alternative term.
What is the main term in the following: Syphilitic aortic aneurysm.Anuerysm
What is the main term in the following: Normal, spontaneous delivery, rull-term infant.Delivery
What is the main term in the following: Acute myocardial infarction.Infaction
What is the main term in the following: Acute suppurative cholecystitisCholecystitis
A dianoses qualified by the term ______ are coded as if established for inpatient episodes of care in the same way that diagnoses described as possible or probable are coded. Rule out
A diagnosis decsribed as _____ is never coded.Ruled out

Section 2

Question Answer
What does the abbreviation NEC stand for?Not elsewhere classified.
What does the abbreviation NOS stand for?Not otherwise specified.
Where would you find NEC and what does it mean?In the alphabetic index to indicate that there is no separate code for the condition even though the diagnostic statement may be very specific.
Where would you find NOS and what does it mean?In the tabular lists and it is the equivalent of "unspecified". To be used only when neither the diagnostic statement nor the medical record provides information that permits classification to a more specific code.
What is "Rule out"?Indicates that a diagnosis is still possible.
What is "Ruled out"?Indicates that a diagnosis once considered likely is no longer possible.
What is a "Late effect"?A residual condition that remains after the termination of the acute phase of an illness or injury.
Late effects include conditions reported as such or as what?As sequela (a condition following and resulting from a disease), of a previous illness or injury.
What index and how is dual classification (multiple coding) identified?In the Alphabetic Index by the use of a second code in brackets.
In dual coding (mandatory multiple coding), the first code identifies _________ and the second code identifies the _________?Underlying condition - Manifestation.
What is a combination code?A single code used to classify either two diagnoses, or a diagnosis with an associated secondary condition, or a diagnosis complication.
What is dual classification?Used to describe the required assignment of two codes to provide information about both a manifestation and the associated underlying disease.
In mandatory multiple coding (dual classification) what goes second in the coding sequence?The code in brackets.
If a patient has SIRS due to an infection they are also considered to have ?Sepsis

Section 3

Question Answer
In the diagnostic statements terms that would be considered as late effects include terms such as?Late - Old - Due to previous injury or illness - Following previous injury or illness - Traumatic, unless there is evidence of current injury.
What are terms for closed operational approaches?Laparoscopic (endoscope used for examination of the abdomen), Thoracoscopic (endoscope used for examination of the chest), and Arthroscopic (endoscope used for examination of the interior of a joint).
When it is necessary to shift from a closed approach to an open surgical approach to complete the surgery what type of code would be used to indicate this?A V code is used from a closed to an open approach.
When a planned procedure is canceled after the patient has been admitted, a code from what category would be assigned?V64
A code from category V64 is considered what?Persons encountering health services for specific procedures not carried out.
What are Vcodes?Factors influencing health status and contact with health services.
What is a principal procedure?It is performed for definitive treatment (rather than for diagnostic or exploratory purposes).
What is eponym from a medical context?The name of the surgeon or surgeons who developed the procedure.
What is bacteremia?Presence of bacteria in the bloodstream after a trauma or infection.
What is sepsis?Refers to SIRS (systemic inflammatory response syndrom) due to infection.
What is septicemia?A systemic disease associated with pathological microorganisms or toxins in the bloodstream, which can include bacteria, viruses, fungi or other organisms.
What is Septic shock?Circulatory failure associated with severe sepsis.
What is SIRS?Systemic inflammatory response syndrome; a systemic response to infection or trauma with such symptoms as fever and tachycardia.
What is severe sepsis?Generally refers ciruclatory failure assocatied with sepsis and therefore repersents a type of acute organ dysfunction.

Section 4

Question Answer
The coding of SIRS, sepsis, and severe sepsis requires a minimum of ____ codes.Two.
How are codes for SIRS, sepsis, and severe sepsis sequenced?The underlying cause (such as infection or trauma 038.xx, 112.5, etc.) is first followed by a code from subcategory 995.9x (systemic inflammatory response/SIRS), and in the case of severe sepsis, an additional code or codes for the associated acute organ dysfunction should be assigned.
When sepsis or severe sepsis develops after admission, the systemic infection code and code 995.91 or 995.92 are assigned as _________.Secondary diagnoses.
How many codes are required for postoperative septic shock?Four.
What order would codes for postoperative shock be assigned?Assign code 998.59 first (other postoperative infection), e.g., 038ss, 112.5, and so forth (code for systemic infection), 998.02 (postoperative septic shock), 995.92 (severe sepsis).
What code should be assigned for all types of HIV infections?042 (Human Immunodeficiency virus (HIV) disease.
Code 042 is not assigned when the diagnostic statement indicates that the infection is "suspected", "possible", likelye", or "?"
When an asymptomatic patient with no prior diagnosis of HIV infection or positive-HIV status requests testing to determine his or hier HIV status, use code ______, Screening for other specified viral disease.V73.89
When a patient is admitted for treatment of an HIV infection or any related complications, code _____ is sequenced as the principal diagnosis, with additional codes for the related conditions. 042 (Human Immunodeficiency virus (HIV) disease.
When a patient with an HIV infection is admitted for treatment of an entirely unrelated condition, such as an injury, what should be sequenced first?The unrelated condition is desginated as the principal diagnosis followed with code 042 and codes for any associated conditions assigned as additional codes.
When the main term for the condition has been located what is the secquencing for an organism (bacterial) and site or other suberm are to be coded?Organism is coded before the suberm (such as "acute" or "chronic").
What should the coder refer to when the orgnaism (bacterial) is specified but is not indexed under the main term for the condition?Refer to the main term "Infection" or to the main term for "organism".
For Drug-resistant infections what do the 4th and fth digits indicate?They type of drug to which the organism has become resitant - indicates whether multiple drugs or those particular types are affected.
Gram ______ bacterial infections are ordinarily more severe and require more intensive care than gram _______ infections. Negative - Positive
Catagory ____ has a fourth digit that identifies the presence of any associated complication and a fifth digit that indicates both the type of diabetes and wheter the patient's status is controlled or uncontrolled.250
Chronic complications in patients with diabetes mellitus requred what type of coding?Dual - A code for the diabetes assigned first, followed by a code for the assocated manifestation indicating the complication.

Recent badges