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ICD-9-CM Test 1
| Question | Answer |
|---|---|
| What does a coder do? | A coder translates medical diagnoses and procedures into a numeric system for the purpose of statistically capturing data |
| What coding system is currently used in teh United States for inpatient coding? | ICD-9-CM |
| What does the CM of ICD-9-CM stand for? | clinical modification |
| What are the uses for coded data? | Research, reimbursement, quality imporvement, risk management, clinical pathways, planning. |
| What payment system does Medicare use for facility reimbursement? | MS-DRG |
| Describe the difference between a nomenclature and a classification system? | A nomenclature is a system of names or preferred terminolgy, wheras a classification system is a grouping of like items for storage |
| What nomenclature of disease is used in the US? | SNOMED (systematized nomenclature of medicine) |
| Define a closed classification system | An item may only be classified in one place |
| When was the International Classification of Diseases first adopted by the US? | 1898 |
| When and how often is this system (ICD-9-CM) updated? | It is updated biannually in October and April |
| What four grops constitute the Cooperating Parties? | National Center for Health Statistics, Centers for Medicare and Medicaid Services, American Hospital Association, American Health Information Management Association |
| Who publishes official coding advice and guidance? | Coding Clinic |
| What organizations award coding credentials? | AHIMA (American Health Information Management Association) and the AAPC (American Academy of Professional Coders) |
| What is another word that is used in the industry for "following the rules"? | Compliance |
| Identification of a disease through signs, symptoms, and tests | Diagnosis |
| Coding software that is used to assign diagnosis and procedure codes | Encoder |
| Moral standard | Ethics |
| The official daily publication for rules, Proposed rules, and notices of U.S. federal agencies and organizations | Federal Register |
| System of names that are used as the preferred terminology | Nomenclature |
| A diagnostic or therapeutic process performed on a patient | Procedure |
| payment for healthcare services | Reimbursement |
| True or False Procedures for processing claim rejections should be included in a coding compliance plan. | True |
| True or False An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere | True |
| The ICD-9-CM classification system is a closed system composed of | Diseases,surgeries,symptoms,injuries |
| If a condition of a patient is being clinically evaluated, the coder would expect to see | Clinical observation |
| Without the ____________________ system, the comparison of data would be impossible. | Classification |
| What appendix is a complete listing of all the three-digit code categories in ICD-9-CM? | Appendix E: List of Three-Digit Categories has a complete listing of all the three-digit code categories |
| ____________________, a form of punctuation, are used in the index to identify manifestation codes in the Alphabetic Index | Brackets |
| If a patient has hives (708.9) due to a medication and if you did not follow the “____________________” instruction, you would assign the wrong code. | See also |
| A ____________________ is a term that is enclosed in parentheses following a main term or a subterm, whose presence or absence has no effect on code assignment. | Nonessential modifier |
| True or false The coder should rely solely on the discharge summary to capture all the diagnoses and procedures treated and performed | False |
| There is an alphabetic index to diseases and an alphabetic index to procedures. | True |
| True or False V codes do NOT indicate a reason for an encounter | True |
| True or false A patient with COPD is admitted to the hospital. Two days after admission, the COPD becomes exacerbated. The exacerbation of the COPD should be designated as present on admission. | False |
| Why is the discharge summary not the only document from which codes are captured? | Coders may not have a discharge summary at the time of coding. |
| Why is the discharge summary not the only document from which codes are captured? | If the patient is in the hospital for a long stay, often the attending physician will be focused only on those diagnoses that occurred in the latter part of the stay. |
| Why is the discharge summary not the only document from which codes are captured? | Physicians list diagnoses that are not currently being treated and are only in the patient’s history. |
| is the process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled based on the documentation in the health record | optimization |
| What is a true characteristic of significant procedures? | 1.surgical in nature 2.carries a procedural risk 3.carries an anesthetic risk 4.requires specialized training |
| The UHDDS (Uniform Hospital Discharge Data Set) elements that need to be captured include which of the following? | date of the procedure and NPI(National provider identifier) |
| There are some instances in which a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This would be an example of when a _____ would be coded. | closure |
| ____________________, if available, is the first step in the process of record review for code selection. | discharge summary |
| are used in the tabular list to enclose synonyms, alternative wording, or explanatory phrases. | Brackets |
| Codes that are used when the information in the health record provides detail for which a specific code does not exist are called ____________________ codes. | other |
| is the removal of tissue for pathologic examination to establish a precise diagnosis | Biopsy |
| The ____________________ Act was responsible for the establishment of the Medicare program. | Social Security |
| DRGs were developed at Yale University in the late 1960s to ____________________ and ____________________. | monitor quality of care, utilization of services |
| is a preexisting condition (it is present on admission) of hospitalization. | comorbidity |
| Medicare is responsible for over ___________ of patients | 50% |
| What is the subterm for subterm of Klebsiella pneumonia | Klebsiella |
| A patient is admitted to the hospital with vomiting, diarrhea, and the inability to eat or drink. IV fluids are administered.The following day, the patient is discharged with a diagnosis of gastroenteritis and dehydration. Principal diagnosis is? | Either could be principal diagnosis |
| How do you calculate case mix index | To calculate the case mix index, add the relative weight for patients discharged in a specific period, and divide by the number of patients discharged in that period |
| When coding a record, where is the best place to begin? | The discharge summary as it summarizes the events of the hospital stay |
| What report in the record must be on the record within 24 hours? | Operative Report |
| What does the term "integral" mean? | that if a condition is an essential part of a disease process it is not separately coded |
| Name a reason why a coder should query a physician? | could include unclear or questionable diagnosis; evidence of treatmentdiagnosis; to determine if a condition is due to a postop complication; to determine if an organism is the cause of a diagnosis; to determine a more specific site or diagnosis |
| Where in the record would a coder find the admitting diagnosis? | The emergency record if applicable or in the physician's admission orders |
| It is important for the __________ and the _____________ be included for every note. | date and the identity of the physician |
| An element that determines a MS-DRG | principal diagnosis |
| Is a MRI and example of a diagnostic procedure? | Yes |
| Is surgery a form of therapeutic treatment? | Yes |
| The ICD-9-CM uses ________________ format for ease in reference | indented |
| This abbreviation in the index represents "other specified", when a specific code is not available for a condition, the index directs the coder to the "other" specified" code in the tabular | NEC "Not elsewhere classifiable" |
| This abbreviation in the tabular represents "other specified". When a specific code is not available for a condition, the tabular includes an _______ entry under a code to identify the code as the "other specified" code | NEC "Not elsewhere classifiable" |
| This abbreviation in the tabular is the equivalent of unspecified | NOS "Not otherwise specified" |
| are used in the Tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category | colon |
Created by:
rhonda6975