NHA Flash Cards

What is anatomy?

The study of body structures.

What is physiology?

The study of how the body functions.

What is pathology?

The study of disease and abnormal conditions.

What does the suffix -itis mean?

Inflammation.

What does the suffix -ectomy mean?

Surgical removal.

What does the suffix -otomy mean?

Incision or cutting into.

What does the suffix -ostomy mean?

Surgical creation of an opening.

What does the suffix -algia mean?

Pain.

What does the suffix -emia mean?

A blood condition.

What does the suffix -megaly mean?

Enlargement.

What does the suffix -scopy mean?

Visual examination.

What does the suffix -plasty mean?

Surgical repair.

What does the suffix -rrhage mean?

Excessive bleeding.

What does the suffix -rrhea mean?

Flow or discharge.

What does the suffix -pathy mean?

Disease.

What does the suffix -logy mean?

Study of.

What does brady- mean?

Slow.

What does tachy- mean?

Fast or rapid.

What does hyper- mean?

Excessive or high.

What does hypo- mean?

Below, low, or deficient.

What does peri- mean?

Around.

What does endo- mean?

Within.

What does epi- mean?

Upon or above.

What does intra- mean?

Within.

What does sub- mean?

Under.

What does poly- mean?

Many.

What does oligo- mean?

Few or scanty.

What does anterior mean?

Toward the front of the body.

What does posterior mean?

Toward the back of the body.

What does superior mean?

Above or toward the head.

What does inferior mean?

Below or toward the feet.

What does medial mean?

Toward the body’s midline.

What does lateral mean?

Away from the body’s midline.

What does proximal mean?

Closer to the point of attachment.

What does distal mean?

Farther from the point of attachment.

What does superficial mean?

Near the body’s surface.

What does deep mean?

Farther from the body’s surface.

What does the sagittal plane divide?

The body into right and left portions.

What does the midsagittal plane divide?

The body into equal right and left halves.

What does the frontal/coronal plane divide?

The body into anterior and posterior portions.

What does the transverse plane divide?

The body into superior and inferior portions.

What does the cardiovascular system include?

The heart and blood vessels.

What is the primary function of the respiratory system?

Gas exchange and breathing.

What organs are part of the urinary system?

Kidneys, ureters, bladder, and urethra.

What does the digestive system do?

Breaks down food and absorbs nutrients.

What does the endocrine system produce?

Hormones.

What does the nervous system include?

Brain, spinal cord, and nerves.

What does the musculoskeletal system include?

Bones, muscles, joints, and connective tissue.

What does the integumentary system include?

Skin, hair, and nails.

What is the primary function of the immune/lymphatic system?

Protect the body against disease and infection.

What organ pumps blood throughout the body?

The heart.

Which organs filter blood and produce urine?

The kidneys.

What is a SOAP note?

A method of documenting patient information using Subjective, Objective, Assessment, and Plan.

What does S in SOAP stand for?

Subjective.

What does O in SOAP stand for?

Objective.

What does A in SOAP stand for?

Assessment.

What does P in SOAP stand for?

Plan.

What is subjective information?

Information reported by the patient.

What is objective information?

Observable or measurable information such as vital signs and test results.

What is the assessment?

The provider’s clinical assessment or diagnosis.

What is the plan?

The treatment plan and next steps.

What fundamental coding principle applies to undocumented services?

If it isn’t documented, it wasn’t done.

Should a coder assume an undocumented diagnosis?

No.

What does HIPAA stand for?

Health Insurance Portability and Accountability Act.

What does PHI stand for?

Protected Health Information.

What is PHI?

Individually identifiable health information related to a person’s health, healthcare, or payment for healthcare.

What does the HIPAA Privacy Rule regulate?

The use and disclosure of protected health information.

What does the HIPAA Security Rule protect?

Electronic protected health information.

What is the minimum necessary principle?

Limiting PHI use or disclosure to what is reasonably necessary for the intended purpose.

Is accessing a patient’s record without a legitimate need acceptable?

No.

Should passwords be shared with coworkers?

No.

Should PHI be discussed where unauthorized people can hear it?

No.

What is beneficence?

Acting for the patient’s benefit.

What is nonmaleficence?

The principle of doing no harm.

What is autonomy?

Respecting the patient’s right to make decisions.

What is justice?

Treating patients fairly.

What is veracity?

Truthfulness.

What is fidelity?

Keeping commitments and responsibilities.

What is medical coding?

Converting medical documentation into standardized codes.

What is the primary purpose of ICD-10-CM?

Reporting diagnoses and health conditions.

What is the primary purpose of CPT?

Reporting procedures and professional services.

What is HCPCS Level II used for?

Supplies, equipment, medications, ambulance services, and other applicable services.

What is the basic coding rule?

Code what is documented.

Should a coder choose a code because it provides higher reimbursement?

No.

Should a coder guess when documentation is insufficient?

No.

What does ICD-10-CM stand for?

International Classification of Diseases, 10th Revision, Clinical Modification.

What is the Alphabetic Index used for?

Locating possible diagnosis codes.

What should be done after finding a code in the Alphabetic Index?

Verify the code in the Tabular List.

What is the Tabular List?

The section containing complete code descriptions and coding instructions.

Where are Excludes notes found?

In the Tabular List.

What is an Excludes1 note?

It generally means the two conditions should not be coded together.

What is an Excludes2 note?

It means the excluded condition is not part of the coded condition, but both may be coded when appropriate.

What does laterality identify?

The side of the body affected.

What are common laterality choices?

Right, left, or bilateral.

What is a placeholder X?

A character used when necessary to hold a position so a required 7th character can be placed correctly.

What is a 7th character used for?

Additional information required by certain code categories, such as encounter or healing information.

What does 'Code First' mean?

The underlying condition should be sequenced first.

What does 'Use Additional Code' mean?

An additional code may be required to fully describe the condition.

What does 'with' sometimes indicate?

An assumed or classified relationship between certain conditions.

Should the unspecified code be used when laterality is documented?

No.