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Questions and Answers
What is the main purpose of the chief complaint (CC) in a medical encounter?
What is the main purpose of the chief complaint (CC) in a medical encounter?
- To provide a description of symptoms or the reason for seeking medical care. (correct)
- To determine the external cause of an injury.
- To list all diagnoses previously assigned to the patient.
- To establish a diagnosis at the end of the encounter.
Which of the following terms refers specifically to a patient's main reason for the visit?
Which of the following terms refers specifically to a patient's main reason for the visit?
- First-listed code (correct)
- External cause code
- Diagnostic statement
- Combination code
What defines an acute condition?
What defines an acute condition?
- It is caused by a chronic disease with sudden severe symptoms. (correct)
- It requires long-term management and monitoring.
- It persists for a long duration with mild symptoms.
- It can occur at any time without a specific onset.
What does the term 'laterality' refer to in a medical diagnosis?
What does the term 'laterality' refer to in a medical diagnosis?
What is a combination code used for?
What is a combination code used for?
Which term is synonymous with the primary diagnosis in outpatient claims?
Which term is synonymous with the primary diagnosis in outpatient claims?
What does an external cause code indicate?
What does an external cause code indicate?
Which of the following best describes an eponym in medical terminology?
Which of the following best describes an eponym in medical terminology?
What is the significance of GEMS in medical coding?
What is the significance of GEMS in medical coding?
What is referred to as the principal diagnosis in an inpatient claim?
What is referred to as the principal diagnosis in an inpatient claim?
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Study Notes
Chief Complaint (CC)
- Patient's description of symptoms or reason for seeking medical care.
- If a diagnosis is not established, codes are assigned for the patient's symptoms.
Diagnostic Statement (DX)
- Physician's description of the patient's encounter.
- May include a specific diagnosis or list of symptoms/related conditions.
Acute Condition
- Symptoms are sudden, severe, and short in duration.
- Can result from a chronic disease causing sudden, severe symptoms.
Eponym
- Diagnosis named after the physician or scientist who established the syndrome or group of symptoms.
- Example: Angelman's syndrome, named after Dr. Harry Angelman.
Laterality
- Diagnosis or injury of one side of the body (right or left).
- Diagnosis codes can be specific to laterality, identifying the affected side.
Combination Code
- Single diagnosis code identifying both the etiology (cause) and manifestation of a condition.
- Example: Diabetes (etiology) causing retinopathy and macular edema (manifestations).
- Used instead of separate codes when available.
First-Listed Code (Primary Diagnosis/Principal Diagnosis)
- Main reason for patient's encounter.
- Listed first on the claim form when multiple diagnosis codes are assigned.
- Primary Diagnosis is used for outpatient claims.
- Principal Diagnosis is used for inpatient claims.
External Cause Code
- Assigned for the situation that caused the injury.
- Example: Codes for vehicle accidents to support a broken leg diagnosis.
GEMS (General Equivalence Mappings)
- Used during the transition from ICD-9-CM to ICD-10-CM to translate codes between the sets.
- This conversion was the responsibility of CMS (Centers for Medicare & Medicaid Services).
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