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Chapter 5 Coding
| Fill in the | blank |
|---|---|
| When submitting insurance claims for patients seen in a physician’s office or in an outpatient hospital setting, the ___________________________diagnosis is listed first | Primary diagnosis |
| When submitting insurance claims for patients seen in a inpatient hospital setting, the ___________________________diagnosis is used. | Principal diagnosis |
| Claims to insurance carriers oftentimes are denied due to lack of ___________________________, which indicates that the procedure provided was not payable for the diagnosis submitted. | medical neccesity |
| The abbreviation ICD-10-CM means ________. | International Classification of Diseases Tenth Revision Clinical Modification |
| The official version of the International Classification of Diseases was developed by the__________. | World Health Organization |
| ICD-10-CM requires ___________________________ documentation in the medical record than the previous coding system, ICD-9-CM. | greater |
| ICD-10-CM is the coding system for reporting inpatient services by hospitals and replaces ___________________________ of the ICD-9-CM coding system. | Volume 1 & 2 |
| ICD-10-CM is the standard code set required under ___________________________ legislation and must be used by covered entities when assigning diagnostic codes. | HIPPA |
| Volume 2, Diseases, is a/an ___________________________index or listing of code numbers | Alphabetic |
| Volume 1, Diseases, is a/an ___________________________listing of code numbers | Tabular |
| When using the ICD-10-CM coding system, the ___________________________ is used as a placeholder to save space for future code expansion. | X |
| Conventions are ___________________________used in the diagnostic code books to assist in the selection of correct codes for the diagnosis encountered. | Rules or principals |
| The abbreviation NEC appearing in the ICD-10-CM code book means __________________________. | Not elsewhere classifable |
| ___________________________ are used to enclose synonyms in the Tabular List. | Brackets |
| If a condition is documented in the medical record, but it is not specified as to whether the condition is acute or chronic, then the ___________________________ code should be assigned | default code |
| When selecting a code that corresponds with the condition stated in the medical record, the coder should first locate the term in the ___________________________and then confirm the code in the____. | alphabetic index, tabular list |
| The instructional note ___________________________ listed in the Tabular List assists the coder as to when it is appropriate to report a secondary code. | dash |
| A condition that is produced after the acute phase of an illness is listed as the main term ___________________________in the Alphabetic Index | sequela or late effect |
| When reporting a condition which affects the left side of the patient, the character _______ is reported to indicate laterally | 2 |
| The neoplasm table has column headings for __________, and ___________. | Malignant , benign |
| In juvenile diabetes, the patient’s _____________________ does not function and produce enough insulin. | pancreas |
| When coding for diabetes in pregnancy, a code from category ______ is assigned as the primary diagnosis. | 024 |
| _________hypertension is indicative of a life-threatening condition. | Malignant |
| Full-term uncomplicated _________________________ deliveries are always reported with the code O80. | vaginal |
| When reporting accidents and injuries, a seventh character of “A” identifies that the encounter is __________. | inital |
| If documentation states that the incident related to a poisoning was a suspected suicide attempt, the code would be reported from the column entitled ___________________________.” | undetermined |
| If a patient falls and fractures his or her wrist, the fracture code is the primary code, followed by a/an ___________________________code to explain how the accident occurred. | External cause |