Question 1

What is the subterm in "aspiration pneumonia"?

Accepted Answer

Aspiration

Question 2

Which of the following is/are a reason(s)why the discharge summary is not the only document from which codes are captured?

Accepted Answer

A) Coders may not have a discharge summary at the time of coding. 
B) If the patient is in the hospital for a long stay,the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay. 
C) Physicians list diagnoses that are not currently being treated and are only in the patient's history. 
D) All of the options are correct. 
A) Coders may not have a discharge summary at the time of coding. 
B) If the patient is in the hospital for a long stay,the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay. 
C) Physicians list diagnoses that are not currently being treated and are only in the patient's history. 
D) All of the options are correct. D

Question 3

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

Accepted Answer

A) True 
 B)False  True

Question 4

What is the main term in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the main term in "rheumatoid...

Question 5

What is the main term in "calculus of the ureter"?

Accepted Answer

The answer of What is the main term in "calculus...

Question 6

What is the subterm in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the subterm in "rheumatoid arthritis"?...

Question 7

The first step in coding the principal diagnosis is to ____.

Accepted Answer

A) identify the diagnosis and the principal procedure 
B) identify main term(s)in the Alphabetic Index 
C) review the medical record 
D) review any subterms under the main term in the Index 
A) identify the diagnosis and the principal procedure 
B) identify main term(s)in the Alphabetic Index 
C) review the medical record 
D) review any subterms under the main term in the Index

Question 8

The main term in "aplastic anemia" is ____.

Accepted Answer

A) anemia 
B) aplasia 
C) aplastic 
D) none of the above 
A) anemia 
B) aplasia 
C) aplastic 
D) none of the above

Question 9

MATCHING
Match the following with the correct term or definition.
-Modifiers of the main term that have an effect on the appropriate code choice

Accepted Answer

A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers 
A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Question 10

When evaluating an ER record,a coder should look for the ____.

Accepted Answer

A) diagnosis 
B) chief complaint 
C) probable diagnosis 
D) differential diagnosis 
A) diagnosis 
B) chief complaint 
C) probable diagnosis 
D) differential diagnosis

Question 11

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Accepted Answer

A) True 
 B)False

Question 12

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Accepted Answer

A) True 
 B)False

Question 13

MATCHING
Match the following with the correct term or definition.
-Emergency Room

Accepted Answer

A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers 
A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Question 14

The main term is ____.

Accepted Answer

A) always identified in italics 
B) a review of the patient's hospital course 
C) a term identifying disease conditions or injuries 
D) a word found in parentheses that enclose explanatory information that does NOT affect the code 
A) always identified in italics 
B) a review of the patient's hospital course 
C) a term identifying disease conditions or injuries 
D) a word found in parentheses that enclose explanatory information that does NOT affect the code

Question 15

What is the main term in "esophageal reflux"?

Accepted Answer

The answer of What is the main term in "esophageal...

Question 16

What is the subterm in "esophageal reflux"?

Accepted Answer

The answer of What is the subterm in "esophageal reflux"?...

Question 17

MATCHING
Match the following with the correct term or definition.
-When a patient displays a symptom that could represent a variety of diagnoses

Accepted Answer

A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers 
A) Tabular List 
B) See also 
C) Subterms 
D) Discharge summary 
E) Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Question 18

What is the main term in "aspiration pneumonia"?

Accepted Answer

The answer of What is the main term in "aspiration...

Question 19

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

Accepted Answer

A) True 
 B)False

Question 20

What is the subterm in "infantile eczema"?

Accepted Answer

The answer of What is the subterm in "infantile eczema"?...

Exam 4: Basic Steps of Coding

What is the subterm in "aspiration pneumonia"?

Which of the following is/are a reason(s)why the discharge summary is not the only document from which codes are captured?

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

What is the main term in "rheumatoid arthritis"?

What is the main term in "calculus of the ureter"?

What is the subterm in "rheumatoid arthritis"?

The first step in coding the principal diagnosis is to ____.

The main term in "aplastic anemia" is ____.

MATCHING Match the following with the correct term or definition. -Modifiers of the main term that have an effect on the appropriate code choice

When evaluating an ER record,a coder should look for the ____.

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

MATCHING Match the following with the correct term or definition. -Emergency Room

The main term is ____.

What is the main term in "esophageal reflux"?

What is the subterm in "esophageal reflux"?

MATCHING Match the following with the correct term or definition. -When a patient displays a symptom that could represent a variety of diagnoses

What is the main term in "aspiration pneumonia"?

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

What is the subterm in "infantile eczema"?

The Rationale for and History of Coding

The Health Record As the Foundation of Coding

ICD-10-Cm Format and Conventions

General Coding Guidelines for Diagnosis

Introduction to ICD-10-PCS

General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures

Coding Medical and Surgical Procedures

Symptoms, signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Certain Infectious and Parasitic Diseases

Neoplasms

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Endocrine, nutritional, and Metabolic Diseases

Mental, behavioral, and Neuro developmental Disorders

Diseases of the Nervous System, diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous Tissue

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, childbirth, and the Puerperium

Certain Conditions Originating in the Perinatal Period and Congenital Malformations, deformations, and Chromosomal Abnormalities

Injuries and Certain Other Consequences of External Cases and External Causes of Morbidity

Burns, Adverse Effects, and Poisonings

Complications of Surgical and Medical Care

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