ICD-10
A patient was admitted into the hospital as an inpatient for a total abdominal hysterectomy. Which code set would be used by the hospital to report for the procedure?
ICD-10-PCS
A separate diagnosis existing in the same patient at the same time as an unrelated diagnosis is known as a:
co-morbidity.
A patient’s subjective description of feeling is known as a
symptom.
When a specialist is asked by an attending physician to evaluate a patient’s condition, a report is written and sent over to be included in the patient’s medical record in the requesting physician’s files, as well as those belonging to the consulting physician. You can locate this information in the:
Consultations Reports.
The suffix -phobia means:
fear
Explains what the provider did for the individual, the action, example: surgery
Procedure
is to ask; an official request to the attending physician for more specific information related to a patient’s condition or treatment
Query
This document or section includes the patient’s demographic information, as well as health insurance policy numbers and the name of the individual who will be financially responsible for the patient’s care.
Patient’s Registration Form
At the time a patient is released from a facility, such as a hospital, this document provides the conclusions and results of the patient’s stay in the facility in addition to follow-up advice.
Discharge Summary
The suffix -ectomy means
to remove
why are diagnosis codes important?
They establish the case for medical necessity.
When should a coder query the physician?
when there is unclear or missing information necessary to code an encounter
If another physician or health care provider referred this patient for a consultation, you will need to have a _____________ to determine the correct evaluation and management code.
Referral Authorization Form
The documentation of each patient encounter should include:
the date
the reason for the encounter
appropriate history and physical exam in relationship to the chief complaint
a plan of care
Thrombolysis means:
dissolve dangerous clots in blood vessels
Susan had a total mastectomy performed. What root operation character will be used?
T Resection
A cause-and-effect relationship between an original condition that has been resolved with a current condition is known as a
Sequela
Results of testing performed on blood, tissue, and other specimens hold important keys to the patient’s condition. The results can provide you with important details necessary for you to determine a specific, accurate code. You can locate this information in the:
Pathology and Laboratory Reports.
The written plan of care should include
treatments and medications, specifying frequency and dosage
ICD-10-PCS codes may include any letter of the alphabet except the letter______.
O
A condition that caused or developed from the existence of another condition is called a:
manifestation.
When querying a provider, what is the best approach in asking the questions?
open-ended or multiple choice
Essentially, this document, written by the admitting physician, explains the background and current issues used to make the decision to admit the patient into the hospital.
History and Physical
details include the patient’s name, address, date of birth, and other personal details, not specifically related to health.
demographic
Mr. Clarkston was taken to the operating suite to have a lithotripsy performed for kidney stones. What root operation character will this surgery be?
F Fragmentation