MEdical coding - exam 1 Intro
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| Nomenclature | systematic listing of proper names
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| Classification | grouping together of similar items
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| Nomenclature of Diseases and Operations | Diseases classified according to both anatomical location and the etiology, or cause.
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| Coding | classifying data and assigning a representation for the date. In healthcare coding means the assignment of numbers to represent diseases, procedures and supplies used in the delivery of healthcare.
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| Purpose of coding: | confidentiality, communicate differently, statistics
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| Define: ICD-9-CM | international classification of diseases 9th revision, clinical modifications
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| Volume I is: | Tabular List of diseases
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| Volume II is: | Alphabetical Index of diseases
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| Volume III is: | Tabular list and alphabetical index of procedures
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| Volume I has what major subdivisions? | Classification of diseases and injuries, supplementary classifications (V & E codes), Appendices
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| V codes are: | used to diagnose when there is no problem or conditions (Ex. routine exam)
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| E codes are: | used to diagnose the environment of injury (Ex. weather, external details)
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| Volume I has how many chapters? | 17 chapters that classify conditions according to etiology or by specific anatomical system.
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| etiology: | cause or reason for
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| Volume I is structured by: | sections, categories, subcategories
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| Sections consist of: | group of 3 digit categories that represent a single disease entity or group of similar or closely related conditions (Ex. 240-246)
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| Categories consist of: | 3 digit category representing a single disease entity or a group of similar or closely related condition. (Ex. 520)
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| Subcategories consist of: | 4th digits that provide more specificity or information regarding the etiology, the site, or manifestation. Fourth digit subcategories are collapsable to the 3 digit code level. A 3 digit code cannot be assigned if a category has been subdivided.
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| Fifth digit classifications: | provide even greater specificity.
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| Residual subcategories: | These are codes with titles "Other" and "unspecified". They were developed to classify conditions not assigned to a seperate subcategory; thus every disease always has a code.
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| Supplementary classifications are: | V and E codes
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| V codes are written as: | the letter V followed by 2 numeric digits, a decimal, a fourth digit and possibly a 5th digit. (Ex. V21.34)
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| E codes are written as: | The letter E followed by 3 numeric digits, a decimal, and a fourth digit. (Ex. E357.2)
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| Morphology: | the tissue or body system or organ involved where cancer is prevalent
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| Volume II contains what major sections? | index to diseases and injuries, table of drugs and chemicals, alphabetic index to external causes of injury and poisoning (E codes)
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| Volume II Index: | includes terminology for all codes. 3 levels of index include main term, subterm, carryover lines.
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| Main term: | represents diseases. could be a condition; noun; adjective.
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| Subterm aka | modifier
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| Subterm is: | modifier that affects the selection of an appropriate code for a given diagnosis. They describe essential differences in site, cause, or clinical type.
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| Subterms written as: | Form individual line entries; alphabetical order, printed regular type beginning with lowercase letters, indented 1 standard indention to the right under the main term. More specific subterms are indented farther to the right as needed.
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| "With" and "without" are listed where? | Beginning of all subterms rather than in alphabetical order.
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| Carryover line: | line needed b/c the number of words that can fit on a single line of print in alphabetical index is limited. They are indented 2 indents from preceeding line.
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| nonessential modifiers: | Series of terms in parenthesis that sometimes directly follow main terms as well as subterms. The presence or absence of these terms in the diagnosis has no effect on the selection of the code listed for that main term or subterm.
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| eponym: | name of something named after the person who discovered it, etc.
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| How many index tables are there in the alphabetic index? | 2
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| What are the 2 index tables in the alphabetic index? | hypertension table and neoplasm table
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| conventions aka: | directions
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| What are conventions: | cross reference terms that are directions to look elsewhere before assigning a code.
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| Instructional notations: | clarify information or provide additional information. (Ex. include and exclude notes)
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| Notes: | Instructions to assign a 5th digit, additional coding instructions, define terms, appear in all 3 volumes.
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| How do notes appear in the alphabetic index? | Boxed, set italic type
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| How do notes appear in the tabular list? | located various levels and are not boxed.
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| What is multiple coding? | Situation where more than one code is needed to describe the condition.
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| What are the 2 types of multiple coding? | Mandatory and indescriminate.
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| In mandatory coding, what are multiple codes used for? | One code describes the underlying condition (Cause or etiology of condition)and the other identifies the manifestations.
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| In alphabetic index where is the second code listed for mandatory coding? | In brackets.
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| Indiscriminate multiple coding: | Irrelevent medical information such as signs and symptoms.
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| If additional code appears at beginning of a chapter: | It affects entire chapter.
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| connecting words: | subterms that indicate a relationship between the main terms and an associated condition or etiology in alphabetic index.
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| NEC | not elsewhere classified
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| NOS | not otherwise specified
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| sechon mark: | indicates presence of footnotes
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| lozenge: | used for research purposes only
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| parenthesis: | enclose supplementary words or explanatory information that may or may not be present in the statement of a diagnosis or procedure.
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| square brackets: | used to enclose synonyms, alternative wording, abbreviations and explanatory phrases.
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| slanted brackets: | found only in alphabetic index, enclose a code number that must be used in conjunction witha code immediately preceeding it
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| colon: | used in tabular list after an incomplete term that needs one or more modifiers in order to assign a given category or code.
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| brace: | simplifies tabular list entries and saves printing space by reducing repetitive wording.
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| manifestation: | resulting condition
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| what are 8 basic steps to coding? | identify all main terms, locate each main term in alphabetic index, refer to any subterms indented under main term, follow cross-reference instructions if needed, verify the code selected in tabular list, read and be guided by tabular list, assign codes.
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