Diagnostic Coding Essentials

Flashcards for the chapter on Diagnostic Coding Essentials, covering historical use, coding structure, and guidelines.

Medical coding began as medical classification in __-century England.

17th

The __ established the International List of Diseases in 1920.

League of Nations

In 1946, the International Commission of the __ established the ICD codes.

World Health Organization (WHO)

The edition currently in use in the United States is the __.

ICD-10-CM

The original purpose of medical coding was to collect __ data.

statistical

The United States uses coding for __ purposes.

health insurance reimbursement

Diagnostic coding translates written descriptions of diseases into or codes.

numeric; alphanumeric

Accurate use of the ICD-10-CM manual is essential for accurate translation of medical record’s diagnostic statement into __ codes.

alphanumeric

The ICD-10-CM has a __ list and an Alphabetic Index.

Tabular

Each year the CMS reviews the ICD-10-CM coding manual, and an update is posted on __.

October 1

The Alphabetic Index consists of an alphabetic list of diagnostic terms and related __.

codes

The Table of Neoplasms lists neoplasms by __ location.

anatomic

The Tabular List is divided into __ chapters.

21

Codes with 7 characters typically provide __ about the coded condition.

specificity

A: Initial encounter, D: Subsequent encounter, S: Sequela - This is an example of __ codes.

7 character

Clear “NOT CODED HERE!” messages are part of __ notes in the Tabular List.

Excludes1

Code first notes appear under __ codes indicating that the underlying condition must be sequenced first.

manifestation

Coding Manual begins with the ICD-10-CM Official Guidelines for __ and Reporting (OGCR).

Coding

Section II of the coding guidelines focuses on selection of __ diagnosis.

Principal

The most commonly used format for progress notes is __.

SOAP

The discharge summary includes the patient’s admission date, date of discharge, and __ findings.

H&P

The __ report includes preliminary and final diagnoses along with detailed descriptions of operative procedures.

Operative

A disease, a condition, an adjective, or a noun can determine the main term in the __ statement.

diagnostic

To code effectively in ICD-10-CM, one must abstract the diagnostic statement from the patient's __.

health record

After abstracting the diagnostic statement, it is important to search for the best __ in the Alphabetic Index.

code

Encoder software is commonly used by coders to assist in __ coding.

medical

Signs and symptoms are only coded if the provider has not reached a final __.

diagnosis

Coding the __ involves identifying the underlying cause of disease.

etiology

Multiple coding requires the use of more than one __ when needed.

code

Sequelae are the lingering effects produced by a health condition after the __ phase of an illness has ended.

acute

Complications of care require two criteria: a cause-and-effect __ and appropriate documentation.

relationship

Neoplasms must be coded by their __ or location and behavior.

site

A benign neoplasm is defined as noncancerous, nonmalignant, and has not invaded __ structures.

adjacent

If insulin is documented in the health record, a second code is __ for diabetes coding.

required

Diabetes mellitus codes are combination codes that include type and __ affected.

body systems

Coding for myocardial infarction is done as acute if documented as such or with a duration of __ weeks or less.

8

Hypertension is coded as high blood pressure, unless the diagnostic statement does not contain either term, in which case it is coded as __ blood pressure.

elevated

Chronic kidney disease is classified as hypertensive chronic kidney disease if a cause-and-effect __ is presumed.

relationship

The ICD-10-CM has combination codes for atherosclerotic heart disease with __ angina pectoris.

angina pectoris

For coding complications of pregnancy, the 7th character is assigned for certain categories to identify the __ affected.

fetus

When documenting injuries, assign separate codes for each injury unless a __ code is provided.

combination

Burn codes must be coded separately unless specific __ codes are given.

combination

The place of occurrence guideline is coded from category Y92, which are secondary codes used at the __ encounter.

initial

Category Y93 defines the activity the patient was involved in at the time of __ or when health condition developed.

injury

Chapter 21 of ICD-10-CM is used to describe circumstances or encounters with a healthcare provider when no current __ or injury exists.

illness

The most important aspect of maximizing third-party reimbursement is to code diagnoses to the highest level of __.

specificity

Providers can help coders achieve high specificity through __ documentation.

detailed

Ethical standards in medical coding involve being responsible and knowledgeable to ensure that no __ occurs in the coding process.

fraud

Patient coaching includes adherence to ethical standards and reporting only codes supported by concise __ in the patient’s chart.

documentation

The __ index in ICD-10-CM is used to identify terms related to diseases and associated codes.

Alphabetic

The Tabular List in ICD-10-CM is essential for checking for codes' compliance with guidelines and __ notations.

instructional

The coding process involves determining the correct diagnosis from the diagnostic __.

statement

The main term in the diagnostic statement may be a noun, adjective, or even an __.

eponym

Essential modifiers are found under the main term in the __ Index.

Alphabetic

The coding process typically concludes with assigning the final ICD-10-CM __.

code

A: Initial encounter indicates an __ encounter for coding.

initial

In coding for neoplasms, one must check the type of neoplasm according to the Table of __ in the coding manual.

Neoplasms

Diabetes codes in ICD-10-CM must include body systems affected and the complications of that __.

system

When coding for a complication of pregnancy, the principal diagnosis corresponds to the main circumstances or complication of the __.

delivery

The safety and quality assurance in coding depend on updates from the __.

CMS