Terms
That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
a. Principal diagnosis
b. Definitive diagnosis
c. Secondary diagnosis
d. First listed diagnosis
The HIPAA mandated code set for outpatient diagnoses is:
a. HCPCS
b. ICD-9-CM Volume 3
c. CPT
d. ICD-9-CM Volumes 1 and 2
When using the Alphabetic Index to code a condition documented as impending or threatened, and the terms impending or threatened are not listed as subterms, the coder should:
a. Code the existing underlying condition only?
b. Code the existing underlying condition as well
c. Code the condition as a late effect
d. Code the impending or threatened condition as if it did occur
This is usually the best place for the coder to begin the inpatient coding process because this document contains a recap of the entire hospitalization, summarizing the reason for admission and the tests, medications, and services provided.
a. Discharge summary
b. Face sheet
c. Disposition
d. Abnormal findings
The Patient's Reason for Visit is also known as:
a. The principal diagnosis
b. The secondary diagnosis
c. The patient's chief symptom or ill-defined condition
d. The patient's chief complaint or reason for the encounter
A term that indicates when two codes may be required to report a condition.
a. Mandatory multiple coding
b. Code to highest level of specificity
c. Code first underlying disease
d. See additional code
When two or more conditions meet the definition of principal diagnosis:
a. The codes should be sequenced n alphabetical order
b. The codes should be sequenced in the order the physician wrote them in the medical record
c. The codes may be sequenced in any order
d. Only one code should be listed
These are used to classify outpatient encounters for circumstances other than diseases and injuries.
a. CC codes
b. E codes
c. V codes
d. M codes
When two separate conditions may be the cause of the symptom, the coder:
a. Codes only the symptom
b. Codes only the symptom and one diagnosis
c. Codes only the diagnoses
d. Codes both the symptom and the diagnoses
When a patients presents for an outpatient procedure or ambulatory surgery and the preoperative diagnosis and postoperative diagnosis are different, then:
a. The coder codes the postoperative diagnosis
b. The coder codes no diagnoses
c. The coder codes both diagnoses
d. The coder codes the preoperative diagnosis
If a patient's condition is described as both acute and chronic, according to the ICD-9-CM Official Guidelines for Coding and Reporting:
a. Both conditions should be coded with the acute code first
b. Only the acute condition should be coded
c. Only the chronic condition should be coded
d. Both conditions should be coded with the chronic code first
Documentation supports two diagnoses using either/or or similar terminology, and both conditions are coded.
a. Diagnosis-related group (DRG)
b. Secondary diagnosis
c. Definitive diagnosis
d. Contrasting or comparative conditions
ICD-9-CM Volume 3 procedure codes are used:
a. Only for Medicare claims
b. In the outpatient setting only
c. Instead of HCPCS codes
d. In the inpatient setting only