Acronyms
UHDDS I
UHDDS II
Mixed bag
PCS
100

 benign prostatic hypertrophy

What is BPH?

100

This document normally contains the following elements: 

*Chief complaint (CC)  *History of the present illness (HPI) *Past medical history *Family medical history *Social history *Review of systems * Physical examination *Impression/Assessment * Plan

What is the H&P?

100

Testing and clinical observations, or  consultation are examples of this

What is clinical evaluation?

100

 When the documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent, the coder should do this

What is "issue a query"?

100

 The thoracic nerve is in this body system

What is the Peripheral Nervous System?

200

 complete blood count

What is "CBC"?

200

________requires reporting of other diagnoses that have significance for the specific hospital encounter.

What is UHDDS?

200

Medications, physical therapy, and surgery are examples of this

What is  therapeutic treatment?

200

Essential part of a disease process, that would not be coded when it is considered this

What is Integral?

200

Destruction, Detachment, Excision, Extraction and Resection are root operations that do this

What is remove all or some of a body part

300

chief complaint

What is "CC"

300

A patient is ready to be discharged from the hospital, but develops a condition that requires more intensive investigation, monitoring, or watchful waiting and the discharge is cancelled until the next day. 

This scenario could be an example of this-


What is "extended length of stay"?

300

Defined in the UHDDS as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

What is the Principal Diagnosis?

300

The number of characters in a PCS code

What is 7?

300

Lysis of adhesion is an example of this root operation

What is "Release"?

400

chronic obstructive pulmonary disease


What is COPD?

400

A decubitus ulcer is documented by the physician. The nursing notes document dressing changes or repositioning. This would be a reportable diagnosis as this would be an example of this-

What is "increased nursing care"?

400

When multiple procedures are performed, the procedure performed for the definitive treatment of the principal diagnosis is this-

What is the Principal Procedure?

400

Which character represents the "Root Operation'

What is the third character?

400

The _______is determined by the access location (the external site, of the procedure), the method the external location is entered, and the type of instrumentation used to perform the procedure

What is the "approach"?

500

gastroesophageal reflux disease


What is GERD?

500

A patient is admitted with acute bronchitis. The patient was admitted 2 years ago for an appendectomy and has a history of shingles. In the discharge summary, the physician documents acute bronchitis, status post appendectomy, and a history of shingles. 

Only the Acute Bronchitis is coded because the other conditions are _______

What is previous condition?

500

Tests are often done to determine the underlying cause. Examples of this include biopsies, imaging, colonoscopy.

What is diagnostic procedure?

500

The body part value for "products of conception", is found in this Section

What is "Obstetrics"?

500

The objective of an embolization procedure to completely close a vessel, would be coded to this root operation

What is "occlusion"?

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