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Standards Section 1
Coding Classification Standards CIHI
| Question | Answer |
|---|---|
| What rare disorder is present when the body's immune system attacks its own nerves? Weakness and tingling in your extremities are usually the first symptoms and it is sometimes preceded by an infection. It causes nerve damage to the Myelin Sheath. | Guillain-Barre Syndrome |
| What is the main problem for patients who leave without being seen at any point in the visit? | The presenting Complaint |
| When multiple problems are considered the main reason for providing ambulatory care services, the main problem is? | The one responsible for the greatest use of resources. |
| Documentation from allied health professionals ( nurses, crisis team workers and physiotherapists) who are not the main service provider can be used for assignment of what type of codes? | Other problems. |
| The ___________________is the problem that is deemed to be the clinically significant reason for the client’s visit and that requires evaluation and/or treatment or management. This can be a diagnosis, condition, problem or circumstance. | Main Problem (MP) |
| What are the two NACRS codes? | Main Problem (MP) and Other Problem (OP) |
| If you see the word “amended” followed by a date in the title banner of a standard it indicate years when? | • New direction was provided in the standard; • Wording changes were made to clarify the direction; and/or • Examples were modified or new examples added. |
| The_____________ is the source for coding morbidity data. | Clinical record |
| What documentation should be available to coders to ensure data quality for medical care cases? | • Discharge/case summary (must include final diagnoses) • History and physical exam report • Progress notes • Consultation reports • Interventional reports • Diagnostic imaging reports (for specificity) |
| What documentation should be available to coders to ensure data quality for death cases? | • Discharge/case summary (must include final diagnoses) • Provisional autopsy report (when applicable) • History and Physical exam report • Progress notes • Consultation reports • Diagnostic imaging reports (for specificity) |
| What documentation should be available to coders to ensure data quality for newborn cases? | • Mother’s record or copy of delivery record • Newborn physical exam |
| When are revisions to the coding standards are made to keep pace with changing health care models, advancements in health care and technology, and health care information needs. | On a regular basis |
| In 2009, the coding standards moved to a ______________ update cycle to coincide with that of the ICD-10-CA and CCI classifications. | Three-year |
| ICD is variable ______ Classification. | Axis |
| What are the two chapter types in the coding standards? | 1) Special Groups; 2) Body Systems |
| What is generally classified to one of the special group chapters? | Conditions |
| When there is any doubt as to where a condition should be classified, which chapter should take priority? | The special groups chapters |
| When was the Canadian Coding Standards for ICD-10-CA and CCI first introduced? | 2001 |
| What was first iteration of the Canadian Coding Standards entitled? | ICD-10-CA and CCI Coding Guidelines, Volume 5 |
| What did Canadian coders use prior to 2001? | The Coding Sourcebook |
| What is CACS? | Comprehensive Ambulatory Classification System that covers both NACRS and Surgical Daycare cases (whether reported under NACRS or DAD) |
| CACS (Comprehensive Ambulatory Classification System) cells belong within a? | Major ambulatory cluster (MAC). The MAC is assigned after the CACS cell. |
| CMGs identified as ‘Ungroupable’ – alert coders to? | Review the record |
| Who assigns CMGs? | The abstracting system may assign a CMG when the chart is coded. The official CMG is assigned by CIHI once the abstract has been processed. |
| Which system's hormones contribute to homeostasis by regulating the activity and growth of target cells in your body. | The endocrine system |
| What is the most common endocrine disorder that is caused by an inability to produce or use insulin? It is mandatory to code. | Diabetes mellitus |
| A patient presents to the oncology clinic for a chemotherapy session for an active left main bronchus malignancy. How should it be coded? | Main Problem - Chemotherapy session Other Problem - Malignant Neoplasm (Mandatory) |
| How should coders assign suspected, questionable, rule out and possible diagnoses? | As Other problems with a prefix Q (Query Diagnosis) |
| Diagnoses must be supported by physician or primary care provider documentation to be classified as a __________. | MP |
| Diagnoses listed only on death certificates, history and physical or pre-operative anesthetic consults qualify as other problems if ________________. | They meet the definition of an other problem (OP). |
| List the main problem as the _______________ code on the abstract. | first diagnosis |
| Always code to the greatest _________________ supported by the documentation. | degree of specificity |
| Classify all poisonings as accidental unless there is clear documentation of _____________________. | intentional self-harm or undetermined intent. |
| Classify poisonings from illicit drug use as accidental unless there is _______________________________________________. | clear documentation of intentional self-harm or undetermined intent. |
| When multiple drugs are involved in a poisoning, the coder should _________________________. | assign a code for each documented drug |
| When a compound drug (such as Tylenol #3, which is acetaminophen, codeine and caffeine) is involved in a poisoning, the coder should? | assign a code for each drug separately |
| With any accident or poisoning classifiable to W00–Y34, excluding Y06 and Y07, assign a code from ____________________. | U98 Place of occurrence, mandatory, as an other problem. |
| It is mandatory to assign an external cause code from Chapter XX—External Causes of Morbidity and Mortality (V01–Y98), as an other problem with any condition classifiable to __________________. | Chapter XIX—Injury, Poisoning and Certain Other Consequences of External Causes. |
| Diagnosis typing applies to all data submitted to _________________. | Discharge Abstract Database (DAD) |
| The assignment of a diagnosis type to a condition is meant to _____________________________________ as evidenced in the physician documentation. | signify the impact that the condition had on the patient’s care |
| All diagnoses or conditions identified on the DAD abstract must be assigned a _____________________. | diagnosis type |
| Diagnosis types (M), (1), (2), (6), (W), (X) and (Y) are considered: | significant diagnosis types |
| It is mandatory to assign a ICD-10-CA code for any diagnosis/condition meeting the definition of a significant/comorbid diagnosis type, which is? | (M, 1, 2, 6, W, X and Y) |
| What is defined as a condition that coexists in addition to the MRDx at the time of admission or that develops subsequently and meets at least one of the three criteria for significance? | Comorbidity |
| For DAD, the term “comorbidity” refers to which diagnosis type? | diagnosis type (1) or (2) assignment |
| If the following conditions are met, what is it called? 1. Requires Tx beyond maintenance of the pre-existing condition; 2. Increases the length of stay (LOS) by at least 24 hours; and/or 3. Significantly affects the treatment received. | Criteria for Significance |
| If a post-admit comorbidity (Diagnosis Type 2) also qualifies as the MRDx, it must be recorded as: | both the MRDx and as a diagnosis type (2). |
| In DAD, if no diagnosis is provided and no interventions were performed, select the: | first-listed diagnosis as the most responsible diagnosis (MRDx). |
| In ICD-10-CA this symbol is used to indicate a code that represents the etiology or underlying cause of a disease. | dagger symbol (†) |
| Symbol used to indicate a code that represents the manifestation of a disease. Assign diagnosis type (6) or diagnosis type (3) to asterisk codes in accordance with the diagnosis typing definitions | asterisk symbol (*) |
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