question

Summarize the structure, content, and the five conventions that are followed in the Alphabetic Index.

answer

It contains in alphabetic order the main terms that describe all the diseases that are classified in the Tabular List. Main terms may be followed by related subterms or supported by supplementary terms. Five conventions apply to using the index correctly: Turnover lines are indented farther to the right than subterms See cross-references lead the coder to another main term; see also suggest additional possible key terms. Notes provide information on code selection. The abbreviation NEC appears with main terms for which no specific code exists. Multiple codes are required when two codes, the second in brackets and italics, appear after a main term.

question

Summarize the structure, content, and the ten conventions that are followed in the Tabular List.

answer

It contains the codes, which are organized into seventeen chapters according to etiology or body system and are listed in numerical order. Code categories consist of three-digit groupings of a single disease's etiology, site, or manifestation. Further clinical detail is supplied by fifth-digit subclassifications. The ten conventions used in the Tabular List include: Fifth-digit requirement symbol Includes and excludes notes Colons in notes Parentheses around supplementary terms Brackets around supplementary synonyms, alternative wording, or explanations Braces to group-related terms Lozenge for non-WHO codes The abbreviation NOS to indicate the code to use when a condition is not completely described, and the abbreviation NEC for the code to be used when the diagnosis does not match any other available code Bullet (*) for new codes or entries, single triangle or facing triangle for new or revised descriptions. Phrases for multiple code requirements: Codes that are not used as primary appear in italics and are usually followed by an instruction to code first underlying disease or use an additional code.

question

Recognize the chapters that make up the Tabular list.

answer

The 17 chapters are arranged by disease or condition, primarily structured by body system, and address a group of categories or codes.

question

Identify the purpose and correct use of V codes and E codes.

answer

V codes: Identify encounters for reasons other than illness or injury Are used when healthy patients receive routine service, for therapeutic encounters, for a problem that is not currently affecting the patient's condition, and for preoperative evaluations. E Codes: Are never used as primary codes Classify the injuries resulting from various environmental events.

question

List the five steps in the process of assigning diagnosis codes.

answer

Step 1. Review complete medical documentation. Step 2. Abstract the medical conditions from the visit documentation. Step 3. Identify the main term for each condition. Step 4. Locate the main terms in the Alphabetic Index. Step 5. Verify the code in the Tabular List.

question

Three key coding guidelines that are included in the Official Guidelines for Coding and Reporting.

answer

Three key coding guidelines: Code the primary diagnosis first, followed by current coexisting conditions. Code to the highest degree of certainty, never coding inconclusive, rule-out diagnoses. Code to the highest level of specificity, using fifth digits or fourth digits when available.

question

1. What does "ICD" mean in ICD-10

answer

International Classification of Diseases 10th revision

question

2. What does the number "10" represent in ICD-10-CM

answer

10th revision

question

3. What does "CM" represent

answer

Clinical Modification

question

What organization created and helps to maintain the ICD-10 system

answer

Centers for Disease Control and Prevention.

question

What type of system is ICD-10? (Hint: open or closed?)

answer

Closed system

question

What does the "PCS" mean in ICD-10-PCS

answer

Procedure Coding System.

question

What is the earliest date that ICD-10 can be implemented in the U.S.

answer

Date of Compliance October 1st, 2015

question

Who must use ICD-10 mnemonics:MeetPrettyPennyVonMoos

answer

Medical Providers, Payers, and Vendors will use medical codes. Outpatient procedures and physician services WILL NOT be using ICD-10.

question

What do the codes in the ICD-10-CM manual represent mnemonics: Ceasse

answer

DIAGNOSIS Characters 1-3: Category Characters 4-6: Etiology, Anatomic Site, Severity Characters 7: Extension

question

What do the codes in the ICD-10-PCS manual represent?

answer

(Procedure Classification System) Procedures

question

Why is it important to transition to ICD-10 at this time Mnemonics: mee

answer

More Percision managed-care and ambulatory encounters Emerging diseases & medical knowledge Expandability: expand new concepts & allow easier incorporation of codes.

question

ICD-10 new features that differ from ICD-9-CM (locci)

answer

1. Laterality (Left, Right, Bilateral) 2. Obstetric codes identify trimester instead of episode of care 3. Combination codes connecting (diagnoses/symptoms, poisonings/external causes) 4. ICD-10 has 21 chapters, ICD-9 had 17 chapters 5. ICD-10 = 68,000 codes, ICD-9 = 14,000 codes 6. ICD-10 uses full code titles

question

What are the two main purposes of coding in the U.S.

answer

1. Statistics for Tracking diseases (health conditions) and mortality. 2. Completeness: expandability, multi-axial structure, & standardized methodology

question

How many chapters are there in ICD-10-CM

answer

*Tabular List is divided into 21 chapters ?A) Infectious and Parasitic Diseases ?C)Neoplasms ?D) Diseases of Blood & Blood forming Organs ?E)Metabolic, endocrine, and nutritional diseases ?F)Mental, behavioral, and neurodevelopment Disorders ?G)Nervous system diseases. (nervous + Alzheimer's) ?H) Diseases of the eye and adnexa /Diseases of the Ear and Mastoid Process ?I)Circulatory Diseases (heart attacks): ?J)Respiratory System: ?K)Digestive System ?L)Skin and subcutaneous tissue disorders: ?M)Musculoskeletal system diseases: ?N)Genitourinary Disorders ?O)Pregnancy, Childbirth and the Puerperium ?P)Conditions in the Perinatal Period ?Q)Congenital Conditions ?R)Signs ; Symptoms ?S)Injuries and Poisonings ?U - UNUSED ?V)External Causes of Morbidity ?Z)Conditions influencing Health Status

question

How many characters do ICD-10-CM codes have?

answer

3-7

question

What is the first character of an ICD-10-CM code?

answer

Letter

question

What does the letter "X" represent in an ICD-10-CM code

answer

future expansion

question

What does NOS mean?

answer

NOS- Not otherwise specified meaning Unspecified. Insufficient information to assign a more specific code.

question

What does NEC mean

answer

• "Not elsewhere classified" in Index guides to "other specified" in Tabular. • Specific code doesn't exist.

question

Name two features of ICD-10 that will provide more specificity

answer

1. 7th character's for Episode Care, Laterality (specifies which organ or part of the body is involved, location right, left, or bilateral) 2. Combination codes - connecting (diagnoses/symptoms, poisonings/external causes) which reduce the number of codes needed to fully describe a condition

question

What is Volume I in ICD-10

answer

TABULAR List: chronological list of codes.

question

What is Volume II

answer

INDEX: alphabetical list of terms

question

[ ] What do brackets represent

answer

• Tabular List - synonyms, alternative wordings, or explanatory phrases. • Index - Identify manifestation codes.

question

What are main terms? How do you recognize main terms

answer

*bold type* •Represents the pt's disease, disorder injury or symptom. •flush with left Margin • May be general or specific

question

What are subterms? How do you recognize subterms

answer

• Adjectives that describe main term "with" or "without" • Indented lower case, not bold

question

What are non-essential modifiers? How do you recognize them

answer

( ) supplementary words enclosed in Parentheses that help code selection but don't affect code assignment.

question

How many "steps" are there in the coding proces

answer

Two-step process 1. Look up the main term, subterms and non-essential modifiers in the Alphabetic Index 2. Verify the code obtained in the Tabular "Follow any instructional notes found in the Tabular and Determine full extent of characters required for the code to be complete."

question

What is the coder's motto

answer

Trust the index and verify with the tabular

question

Why is it important to always verify your codes in the tabular

answer

Failure to complete both steps may result in an inaccurate and incomplete coding assignment. • code may be incomplete in index • Tabular may require additional character 4-7 •Tabular may require additional code • Tabular may specify order of codes

question

What is meant by "Trust the Index"

answer

If a term is correctly located in the index but the term is not described tabular list, trust that the index directed you to the correct code

question

What are the two types of Excludes Notes? What information do they provide to the coder?

answer

EXCLUDES 1 "Not coded here!" (Mutually exclusive conditions); both codes cannot be used together EXCLUDES 2 "Not included here!" Warning condition excluded is not a part of the code description, *but the two conditions may occur in same patient. (Verify documentation)

question

What is the concept of compliance in healthcare?

answer

Compliance date is based on: the date of discharge for inpatient claims and the date of service for outpatient claims

question

What is the UHDDS? What does it include (No Boys & Girls Run Past It Down eXtreme Paths)

answer

(Uniform Hospital Discharge Data Set) Condition established to be reason for admission of pt for care. Demographics and Coding Requirements: 1.Name 2. Birthdate/ Age 3. Gender 4. Race/ Ethnicity 5. Expected payer 6. Healthcare provider's identification 7. Principal/primary diagnosis 8. Other diagnoses that have significance for the specific hospital episode 9. All significant procedures

question

What is the source document for coding

answer

The patient record

question

What do coders "query the physician" for?

answer

seek clarification of unclear, incomplete, or conflicting chart documentation • No leading questions • Frame the question by presenting clinical evidence that prompted the need for the query.

question

Give three examples of types of documentation that could be used for coding

answer

Pt record's record is source documentation found on: ?Operative Report ?Medical Record ?Super Bill

question

If the insurance company will only reimburse for a service based on a certain diagnosis, is it okay to assign that diagnosis code even if the patient doesn't have that condition

answer

No, against the law

question

What is an ABN (Advanced Beneficiary Notice)

answer

• A waiver of liability, • Written notice informing the pt that the prescribed service may not be covered by Medicare, and that the patient may be liable for payment * * *Must be issued and signed before treatment rendered

question

What is meant by "medical necessity"?

answer

Documented justification that the health care services performed are both reasonable and necessary

question

Define "primary diagnosis".In what setting do we assign the primary diagnosis code?

answer

• Applies to outpatient diagnostic coding only • "The condition that prompted the patient to seek health care services.

question

Can you assign diagnosis codes based on abnormal findings on lab, path, or radiology tests?

answer

Must be interpreted in context by physician

question

Define "principal diagnosis". In what setting do we assign the principal diagnosis code?

answer

1. Main reason for admission to the hospital (1st coded condition) 2. Only used in Acute Inpatient Hospital Coding.

question

What are secondary diagnosis codes? When would you assign secondary diagnosis codes?

answer

• Comorbid Conditions, secondary manifestation, or a diagnosis with an associated complication • Only code when the conditions affect the current episode of care.

question

Is the tabular instruction, "Code first underlying disease", optional or mandatory?

answer

1. Mandatory instruction 2. Code for underlying disease is sequenced first, followed by code for the manifestation

question

Is the tabular instruction, "Use additional code", optional or mandatory

answer

• Mandatory • One or more codes necessary to fully identify specific condition • Implies "cause and effect"

question

What is a combination code?

answer

• Single code that identifies two related diagnoses • Diagnoses/Symptoms • Poisonings/External causes

question

Can you assign codes for conditions that are "possible, probable, or still to be ruled out" for outpatient encounters? If not, why not?

answer

Not unless the physician documented it. "If it's not documented it didn't happen."

question

Name three types of outpatient services.

answer

1. SCREENING for prevention or early detection of disease 2. COUNSELING SERVICES 3. EVALUATION to establish a diagnosis and initiate treatment

question

How many tables are there in ICD-10-CM and name them

answer

1. Neoplasm Table 2. Table of Drugs and Chemicals

question

dx or Dx

answer

Diagnosis

question

initial

answer

when reporting accident and injuries,a 7th char. of 'A' identifies that the encounter is?

question

external cause code

answer

if accident occurs,the primary code is followed by a ___to explain how the accident occurred.

question

primary

answer

in outpatient hospital setting, the __dx is listed first

question

principle

answer

in an inpatient hosp setting, the __dx is used

question

ICD stands for

answer

International classification of disease

question

if its not specified as to a condition is acute or chronic use the ____ code

answer

default

question

WNL

answer

within normal limits

question

DC

answer

discharge

question

RLQ

answer

right lower quadrent

question

R/O

answer

rule out

question

URI

answer

upper respiratory infrection

question

tx

answer

treatment

question

pt

answer

patient

question

hx

answer

history

question

when documenting incisions, the unit of measure of length would be in

answer

centimeters

question

a fracture not indicated as open or closed is classified as

answer

closed

question

a fracture dislocation is coded as a

answer

fracture

question

pathologic or spontaneous

answer

type of break in bone because of disease or tissue that makes the bone weak.

question

sequela

answer

(residual effects) a condition that is the conseq. of a previous injury or disease

question

"late, due to, following"

answer

indicate sequela

question

Z codes

answer

factors influencing health status & contact with health services (guidelines section 1, subsection c, or chap 21)

question

External cause codes are used to

answer

establish injury prevention programs

question

subterm

answer

an essential modifier is also referred to as

question

the existing underlying condition

answer

when conditions docum. as "threatened" are referenced in the Alph Indx, and there is no entry for "threatened", report ..

question

CC

answer

CHIEF COMPLAINT the reason for the visit, from the patients perspective,also the key to determining the first-listed diagnosis

question

report signs and symptoms when..

answer

..if the diagnosis is NOT yet determined

question

outpatient surgery

answer

code the reason for the surgery as the first-listed dx,even if surgery is not performed due to contraindication (Z53.09)

question

Z codes can be used for

answer

inpatient and outpatient

question

the external cause index has its own

answer

alpha index

question

V codes

answer

Z codes were known as what in ICD 10

question

chemical codes begin with

answer

with T for Toxic

question

"or"

answer

"and" should always be read as "and" or "___"

question

HCPCS CPT

answer

aka LEVEL 1

question

HCPCS national codes

answer

aka LEVEL 2 *the skinny manual* ex: non oral drugs, ambulance, supplies etc

question

ICD 10 CM

answer

outpatient procedures/service manual

question

form cms1500

answer

used for outpatient billing

question

form ub04

answer

used for inpatient billing

question

level 1 modifiers

answer

outpatient facilities & professionals (MD) use

question

Z03 and z04

answer

observation codes*reported only as first-listed dx for suspected conditions and conditions ruled out. additional codes can be used with these if unrelated.

question

ICD-10-CM codes are composed of __ to ___ characters.

answer

3, 7

question

The first character is always a(n) ____ except ___.

answer

letter, U

question

A decimal point is used after the character __.

answer

3

question

The alphabetic list of terms

answer

index

question

The chronological list of codes

answer

tabular list

question

The index is made up of what two things?

answer

index to disease and injury, index to external cause of injury

question

the neoplasm table is located in the ___.

answer

index

question

Table of drug and chemical is located in the ___.

answer

index

question

Main Term, ___ __, ___ __ ___...

answer

subterm, more specific subterm

question

Synonyms or condition similar enough to be classified to the same code

answer

inclusion note

question

Means not coded here; the two conditions cannot occur together and therefore cannot be used together

answer

excludes 1

question

Means the patient may have both conditions at the same time; can use both codes

answer

excludes 2

question

identifies a code for a condition that is a manifestation of an underlying disease

answer

code first

question

Indicates that another code may be needed to complete statement of the condition

answer

use additional code

question

There is no separate code for the condition even though the diagnostic statement may be very specific.

answer

NEC

question

NOS is the equivalent of ___.

answer

unspecified

question

Cross reference indicates that the coder MUST refer to an alternative term

answer

See

question

Used to enclose supplementary words or explanatory informration that may be present in the documentation without affecting the code assignment

answer

parentheses

question

Used in Tabular List to enclose synonyms, alternative wordings, abbreviations and explanatory phrases that provide additional information

answer

square brackets

question

Used in alphabetic index to indicate mandatory multiple coding. Both codes must be assigned and the code in the brackets can never be listed first

answer

slanted brackets

question

A baby is considered full term at ___ weeks.

answer

37

question

A baby is considered full term at ___ weeks.

answer

40

question

cervical insufficiency is also called ___ ___.

answer

incompetent cervix

question

Cervix dilates prematurely before the baby is full term

answer

cervical insufficiency

question

Procedure to close cervix to keep it from dilating

answer

cervical cerclage

question

transvaginal means..

answer

via natural

question

Scar tissue of fiber bands that form within the body, usually in abdominal or pelvic cavity

answer

ahesions

question

Root operation to cut or free a body part from an abnormal physical constraint or a body part causing abnormal constraint

answer

release

question

Root Operation to visually and or manually exploring a body part

answer

inspection

question

When inspecting multiple body parts, the body part character is defined as the most ___ body part inspected.

answer

distal

question

Root operation when breaking solid matter in a body part into pieces, not removing

answer

fragmentation

question

Refers to endoscopic lithotripsy procedures is ____ fragmentation.

answer

direct

question

ESWL

answer

extracorporeal shock wave lithotripsy

question

ESWL would be a(n) ___ approach to fragmentation.

answer

indirect

question

ERCP

answer

endoscopic retrograde cholangiopancreatography with lithotripsy

question

refers to ingestion of dye

answer

retrograde

question

Root operation meaning to take or cut out solid matter from a body part

answer

extirpation

question

Top layer of the skin

answer

epidermis

question

Middle layer or the skin containing sweat glands, receptors and blood vessels

answer

dermis

question

Deepest layer of the skin

answer

hypodermis

question

layer below hypodermis

answer

fascia

question

Root Operation of separating without taking out, a body part

answer

division

question

Root Operation of taking or letting out fluids and/or gases from a body part

answer

drainage

question

Root Operation of cutting out or off, without replacement, a portion of a body part

answer

excision

question

Root Operation of taking or cutting out solid matter from a body part

answer

extirpation

question

Root Operation of pulling or stripping out or off all or a portion of a body part by the use of force

answer

extraction

question

Root Operation of breaking solid mater in a body part into pieces

answer

fragmentation

question

___________codes describe patient illnesses, diseases, conditions, injuries, or other reasons for seeking healthcare services.

answer

Diagnosis

question

The three skills of an "ace" coder are to _______ information from the medical record; _______ the accurate code number; and _______ the codes in proper order.

answer

abstract, assign, arrange

question

_______ encounters are physician interactions with patients who have not been formally admitted to a healthcare institution, such as an acute care hospital, long-term care facility, or rehabilitation facility.

answer

Outpatient

question

_______ encounters are physician interactions with patients who have been formally admitted to a healthcare facility, such as an acute care hospital, long-term care facility, or rehabilitation facility.

answer

Inpatient

question

_______ services include laboratory, radiology, or physical therapy.

answer

Ancillary

question

The _______ physician oversees and coordinates all aspects of the patient's care.

answer

attending

question

A _______ is the progression of jobs and responsibilities throughout one's working life.

answer

career path

question

The _______ plan may include medication, surgery, lifestyle changes, or therapy.

answer

treatment

question

When the documentation is unclear, coders _______ the physician for clarification.

answer

query

question

Most coders are expected meet a case _______ standard to code a specific number of cases each day, while maintaining high ________.

answer

production, accuracy

question

The replacement code set used for diagnosis coding is__________.

answer

ICD-10-CM

question

_______ is the replacement code set that is used for hospital inpatient procedure coding.

answer

ICD-10-PCS

question

Which of the following is NOT a HIPAA-mandated code set?

answer

DSM-IV

question

A specific interaction between a patient and healthcare provider is an ___________.

answer

Encounter

question

Which of the following is NOT an example of an outpatient encounter?

answer

Hospital admission

question

Coders do which of the following tasks?

answer

Assign diagnostic and procedure codes for patient encounters after an encounter is completed.

question

Which statement about certification is NOT true?

answer

All states legally mandate coder certification.

question

Most coders look for a (an) _______ job upon graduation in order to gain basic skills, become familiar with the healthcare field, and establish excellent work habits.

answer

Entry-level

question

_______ is an example of an entry-level job.

answer

Data Entry Clerk

question

Many organizations post their job openings _______, available only to current employees, for a period of time before they are advertised to the public.

answer

Internally

question

_______ is hospital insurance that covers a specific list of services for inpatient hospital care, skilled nursing facilities, hospice, and home healthcare.

answer

Part A (Medicare)

question

_______ is a Medicare supplement insurance policy sold by private insurance companies to fill gaps in Part A and Part B coverage.

answer

Medigap

question

_______ is health insurance coverage for family members of active duty personnel and for retired military personnel and their families.

answer

TC (Tricare)

question

_______ is the health status of immediate family members, causes of death (if known), and diseases common in the family.

answer

Family history

question

Each patient encounter is coded based on _______ for that visit.

answer

progress notes

question

The _______ is a statement that lists all the services the provider billed, which ones were accepted for payment, how much the insurance company will pay, how much the patient owes, and how much will not be paid.

answer

EOB (explanation of benefits)

question

_______ is knowingly billing for services that were never given or billing for a service that as a higher reimbursement than the service provided.

answer

Fraud

question

_______ is mistakenly accepting payment for items or services that should not be paid for by Medicare.

answer

Abuse

question

_______ investigates fraud, abuse, and other noncompliance matters in the Medicare and Medicaid programs.

answer

OIG (Office of the Inspector General

question

The OIG issued sample _______ programs, which include seven major characteristics.

answer

compliance

question

Med pay or personal injury protection from automobile insurance policies is regulated by

answer

Each state's Department of Insurance

question

_______ is funded two-thirds by the federal government and one-third by state governments.

answer

Medicaid

question

An example of the medical necessity criterion evidence-based practice is

answer

Medications proven to benefit patients based on scientific studies.

question

The provider verifies eligibility with the insurance company

answer

before the encounter

question

The chart is given to the coding department where a coder reviews the progess note, assigns diagnosis and procedure codes, and enters the codes into the computer

answer

after the encounter

question

The computer system first performs a front-end edit check

answer

at the insurance company

question

Which of the following is NOT a coding problem that causes rejected or denied claims?

answer

The patient's insurance has expired.

question

Knowingly submitting a bill to a government healthcare program, such as Medicare, that contains incorrect codes is considered to be presenting a

answer

false claim

question

The Patient Protection and Affordable Care Act (PPACA), passed in 2010, mandates _______ for providers who contract with Medicare, Medicaid, and SCHIP.

answer

compliance programs

question

The RAC program uses _______ to identify Medicare overpayments and underpayments to healthcare providers and suppliers.

answer

independent contractors

question

ICD-10-CM codes contain _______ to _______ characters.

answer

three, seven

question

ICD-10-PCS codes contain _______ characters.

answer

seven

question

______ is causes of disease and illness.

answer

morbidity

question

The United States version of ICD-10 diagnosis codes is much more _______ than it is in other nations.

answer

granular

question

The code set _______ was developed by WHO for worldwide use.

answer

ICD-10

question

The code set _______ is used only by inpatient hospitals.

answer

ICD-10-PCS

question

Coders already certified through _______ for ICD-9-CM/PCS must complete a specified amount of continuing education, based on their specialty and coding credential, beginning in 2011.

answer

AHIMA

question

_______ uses more combination codes than ICD-9-CM.

answer

ICD-10-CM

question

Which of the following is NOT a benefit of ICD-10-CM?

answer

The structure of the new code set allows physicians to create new codes whenever they need to, if an appropriate code is not already available.

question

Which of the following conditions does NOT require updated terminology in ICD-10-CM?

answer

Influenza

question

Who is required to use ICD-10-CM?

answer

HIPAA-covered entities

question

Which of the following is NOT a requirement that impacts health information systems?

answer

Create separate fields for ICD-9-CM and ICD-10-CM codes.

question

Which of the following is NOT an example of provider documentation changes under ICD-10-CM/PCS?

answer

Acute vs chronic

question

Changes in procedure abstracting under ICD-10-PCS include all of the following EXCEPT

answer

External causes

question

Which of the following areas will impact coders?

answer

Learning new software, Enhanced data entry skills, Expanded medical terminology

question

Which is the most accurate description of GEMs?

answer

An authoritative source for comparing codes between ICD-10-CM/PCS and ICD-9-CM.

question

The convention _______ identifies nonessential modifiers that describe the default variations of a term.

answer

( )

question

The convention _______ identifies mutually exclusive codes that should not be used together.

answer

Excludes1

question

The convention _______ tells the coder that additional characters should be assigned to a code.

answer

-

question

A code that appears in ______ in the Index should be sequenced second.

answer

[ ]

question

The convention _______ appears in front of a four-digit code to indicate that a fifth digit is required.

answer

5th

question

The convention _______ is a placeholder in codes with less than six characters that require a seventh character extension.

answer

X

question

The convention _______ indicates that the condition excluded is not part of the condition represented by the code, but the patient may have both conditions at the same time.

answer

Excludes2

question

The convention _______ instructs the coder to sequence the etiology first.

answer

code first

question

The convention _______ instructs the coder to sequence the manifestation second.

answer

use additional code

question

The convention _______ instructs the coder to reference another Main Term or condition to locate the correct code.

answer

see

question

_______ are the seventh characters of codes that must appear in that position, regardless of the length of the code.

answer

Extensions

question

In the outpatient setting, the ______ diagnosis is the diagnosis, condition, problem, or other reason for the encounter visit shown in the mdeical record to be chiefly responsible for the services provided.

answer

First-listed

question

_______ diagnoses are preceded by the words probable, possible, suspected, questionable, rule out, working diagnosis, or similar word.

answer

Uncertain

question

In an inpatient setting, the _______ diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

answer

principal

question

_______ are rules that complement the conventions and instructional notes to provide additional information and direction in identifying the diagnoses to be reported.

answer

OGCR

question

_______ are the use of symbols, typeface, and layout features to succinctly convey interpretive information.

answer

Conventions

question

_______ means to read the medical record and determine which elements of the encounter require codes.

answer

Abstracting

question

A _______ is a contiguous range of codes within a chapter in ICD-10-CM.

answer

block

question

_______ is a new OGCR that defines separate codes for the right and left sides of the body.

answer

Laterality

question

Do not code signs or symptoms that are a/an _______ part of the disease process when the diagnosis has been established.

answer

integral

question

_________ describes the anatomical site where the neoplasm begins.

answer

primary

question

_________ describes the tissue type.

answer

histology

question

_________ describes a neoplasm that has spread to other sites.

answer

metastasis

question

__________ is the process of determining how far the cancer has spread.

answer

Staging

question

Chemotherapy, radiotherapy, and immunotherapy are examples of _________ therapy.

answer

adjuvant

question

________ uses drugs to kill cancer cells.

answer

Chemotherapy

question

_______ occurs only in epithelial cells.

answer

Carcinoma

question

_______ tumors are contiguous sites where the neoplasm continues from one site to the adjacent one without interruption.

answer

overlapping

question

_________ describes how closely the cancer cell looks like a normal cell when viewed microscopically.

answer

grading

question

___________ means life threatening.

answer

malignant

question

Which of the following is NOT a characteristic of malignant neoplasms?

answer

Produce no cachexia

question

Malignant neoplasms metastasize through

answer

the bloodstream and lymphatic system

question

Personal history of malignant neoplasm is

answer

a condition the patient had in the past, was removed, and is no longer being treated, but has the potential for recurrence

question

Which of the following is NOT a column on the Table of Neoplasms?

answer

Personal History

question

Which of the following statements about the Table of Neoplasms is TRUE?

answer

Codes in the Table of Neoplasms must always be verified in the Tabular List

question

When a patient is seen for evaluation or treatment of metastasis, which code should be sequenced first?

answer

Secondary neoplasm

question

When a patient is seen for dehydration due to colon cancer that has metastasized to multiple sites, which code should be sequenced first?

answer

Dehydration

question

When a patient is admitted for surgery to remove a tumor from the breast, then receives chemotherapy while still in the hospital, which code should be sequenced first?

answer

Breast cancer

question

When a patient receives a colonoscopy more frequently than normal, due to a family history of colon cancer, which code should be sequenced first?

answer

Screening

question

When a patient who previously had surgery to remove a malignant neoplasm of the lung has an encounter only for radiotherapy, which code(s) should be assigned?

answer

Encounter for radiotherapy first and malignant neoplasm second

question

ICD-10-CM

answer

International Classification of Disease, 10th revision, Clinical Modification

question

Code also

answer

instructs coders that 2 codes may be needed to fully code statement

question

Code first

answer

listed in tabular and must be followed, two codes needed with this listed first.

question

Conventions

answer

rules to use in coding that needed to be followed

question

Excludes

answer

used to signify that the conditions are not assigned to this category

question

Excludes 1

answer

diagnostic terms listed are not coded to the category or subcategory. Means cannot be coded together and they can not be related.

question

Excludes 2

answer

a code not usually associated or coded with certain other codes but is not completely restricted from use.

question

Includes

answer

appears under a 3 digit code to further define or give examples

question

NEC

answer

not elswhere classfied, "Other specified", when a specific code is not available.

question

NOS

answer

Not otherwise specified-not enough information from Dr.

question

Essential modifiers

answer

listed below the category, must be in the physician's diagnosis

question

Nonessential modifiers

answer

are used within the paenthesis and do not have to be in diagnosis statement

question

See

answer

instructs the coder to cross reference the term or diagnosis in the Alpha

question

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