Questions and Answers
List the four cooperating parties that agree on coding principles.
AMA, CMS, AHA, AHIMA
Identify the main ________ in the diagnostic statement.
term
Locate the main term(s) in the ________ Index.
alphabetic
Review any ________ under the main term in the index.
Signup and view all the answers
Follow any ___________ ____________ instructions, such as 'see also.'
Signup and view all the answers
Verify the code(s) selected from the Index (Vol.) in the Tabular List (Vol.___) referred to in this text as the Tabular.
Signup and view all the answers
Refer to any instructional notations in the __________ _________.
Signup and view all the answers
Assign codes to the highest level of ___________.
Signup and view all the answers
Code the diagnosis until all _____ are completely identified.
Signup and view all the answers
A combination code is a single code used to classify:
Signup and view all the answers
Additional signs and symptoms that may not routinely be associated with the disease process being reported should be coded when present.
Signup and view all the answers
In the outpatient setting, an impending condition should be coded as if it actually exists.
Signup and view all the answers
When separate codes exist to identify acute and chronic conditions, the chronic code is sequenced first.
Signup and view all the answers
It is acceptable to use only the alphabetic index to assign I-10 codes.
Signup and view all the answers
When sequencing codes for residuals and late effects, the residual is sequenced first followed by the late effect code.
Signup and view all the answers
A code is invalid if it has not been coded to the full number of digits available for that code.
Signup and view all the answers
The Official Guidelines for Coding and Reporting are updated annually.
Signup and view all the answers
List two common symptoms associated with kidney stones.
Signup and view all the answers
List two common symptoms associated with pneumonia.
Signup and view all the answers
What is the code for acute and chronic prostatitis?
Signup and view all the answers
What is the code for headache, stiff neck, and fever due to viral meningitis?
Signup and view all the answers
What is the code for acute and chronic pyelonephritis?
Signup and view all the answers
What is the code for abdominal pain due to acute and chronic cholecystitis?
Signup and view all the answers
What is the code for urinary tract infection due to proteus mirabilis?
Signup and view all the answers
What is the code for cerebrovascular accident, TIA?
Signup and view all the answers
What is the code for traumatic arthritis of the wrist due to fracture 5 years ago?
Signup and view all the answers
What is the code for dysphagia due to previous cerebrovascular accident, nontraumatic?
Signup and view all the answers
What is the code for respiratory syncytial virus (RSV) infection?
Signup and view all the answers
Study Notes
Coding Principles and Key Definitions
-
Four cooperating parties for coding principles: AMA (American Medical Association), CMS (Centers for Medicare & Medicaid Services), AHA (American Hospital Association), AHIMA (American Health Information Management Association).
-
The main term in a diagnostic statement is pivotal for accurate medical coding.
Locating Information Within Indices
-
Main terms can be located in the alphabetic index for precise diagnosis coding.
-
Review subterms under the main term in the index for detailed specificity.
-
Follow cross-reference instructions such as "see also" for additional code guidance and more complete coding.
Verification and Instructional Notations
-
Codes selected from the Index (Vol. 1) should be verified in the Tabular List (Vol. 2) for accuracy.
-
Refer to any instructional notations in the Tabular List, as they provide essential coding guidance.
Specifying Codes
-
Assign codes to the highest level of specificity; use all available digits (e.g., use a five-digit code if available instead of a four-digit code).
-
Ensure all elements of a diagnosis are completely identified before finalizing codes.
Combination Codes and Additional Symptoms
-
A combination code classifies two diagnoses, a diagnosis with an associated manifestation, or a diagnosis with an associated complication.
-
Additional signs and symptoms not routinely linked to a disease should be coded when present to reflect complete clinical picture.
Conditions in Context
-
In outpatient settings, code impending conditions as if they actually exist; this approach clarifies the clinician's intent.
-
When separate codes identify acute and chronic conditions, the acute code is sequenced first, not the chronic code.
-
Using only the alphabetic index for I-10 codes is not acceptable; both the index and tabular list must be utilized for coding accuracy.
-
For residuals and late effects, always sequence the residual code first, followed by the late effect code.
Validity and Guidelines
-
A code is considered invalid if not fully coded to the maximum number of digits available.
-
The Official Guidelines for Coding and Reporting are updated annually to reflect current coding practices and standards.
Common Symptoms and Coding Examples
-
Common symptoms associated with kidney stones: abdominal pain, vomiting, blood in urine.
-
Common symptoms associated with pneumonia: fever, cough.
-
Specific codes for conditions:
- Acute and chronic prostatitis: N41.0, N41.1.
- Viral meningitis with headache, stiff neck, and fever: A87.9.
- Acute and chronic pyelonephritis: N10, N11.9.
- Abdominal pain due to acute and chronic cholecystitis: K81.2.
- Urinary tract infection due to Proteus mirabilis: N39.0, B96.4.
- Cerebrovascular accident, TIA: G45.9.
- Traumatic arthritis of the wrist from fracture (5 years ago): M19.139, S62.90XS.
- Dysphagia due to previous cerebrovascular accident: I69.391.
- Respiratory syncytial virus (RSV) infection: B97.4.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on coding principles and terms in Chapter 4 of 'Step by Step'. This quiz focuses on the essential elements and main terms relevant to the diagnostic statement, ensuring you grasp the key concepts needed for medical coding.
