Acronyms
benign prostatic hypertrophy
What is BPH?
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?
Testing and clinical observations, or consultation are examples of this
What is clinical evaluation?
When the documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent, the coder should do this
What is "issue a query"?
The thoracic nerve is in this body system
What is the Peripheral Nervous System?
complete blood count
What is "CBC"?
________requires reporting of other diagnoses that have significance for the specific hospital encounter.
What is UHDDS?
Medications, physical therapy, and surgery are examples of this
What is therapeutic treatment?
Essential part of a disease process, that would not be coded when it is considered this
What is Integral?
Destruction, Detachment, Excision, Extraction and Resection are root operations that do this
What is remove all or some of a body part
chief complaint
What is "CC"
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"?
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?
The number of characters in a PCS code
What is 7?
Lysis of adhesion is an example of this root operation
What is "Release"?
chronic obstructive pulmonary disease
What is COPD?
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"?
When multiple procedures are performed, the procedure performed for the definitive treatment of the principal diagnosis is this-
What is the Principal Procedure?
Which character represents the "Root Operation'
What is the third character?
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"?
gastroesophageal reflux disease
What is GERD?
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?
Tests are often done to determine the underlying cause. Examples of this include biopsies, imaging, colonoscopy.
What is diagnostic procedure?
The body part value for "products of conception", is found in this Section
What is "Obstetrics"?
The objective of an embolization procedure to completely close a vessel, would be coded to this root operation
What is "occlusion"?