Question 1

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 C

Question 2

Match each definition to one of the following items.
-Have no effect on the main term

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 J

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

Match each definition to one of the following items.
-A cross-reference instruction in the code book

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 6

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

Accepted Answer

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

Question 7

Match each definition to one of the following items.
-Review the health record

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 8

Match each definition to one of the following items.
-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 9

Match each definition to one of the following items.
-The reason, in the patient's own words, for coming to the hospital

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

What is the main term in "aspiration pneumonia"?

Accepted Answer

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

Question 11

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 12

Match each definition to one of the following items.
-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 13

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.

Question 14

After a code has been selected from the Alphabetic Index to Diseases, what is the next step?

Accepted Answer

It must be

Question 15

Match each definition to one of the following items.
-After a code has been selected from the Alphabetic Index, it must be verified in this

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 16

The main terms usually are nouns and/or disease conditions.

Accepted Answer

A) True 
 B)False

Question 17

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

Accepted Answer

A) True 
 B)False

Question 18

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 19

What is the subterm in "aspiration pneumonia"?

Accepted Answer

The answer of What is the subterm in "aspiration pneumonia"?...

Question 20

Match each definition to one of the following items.
-Provides advice on how to correctly code specific 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

Exam 4: Basic Steps of Coding

The main term is ____.

Match each definition to one of the following items. -Have no effect on the main term

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"?

Match each definition to one of the following items. -A cross-reference instruction in the code book

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

Match each definition to one of the following items. -Review the health record

Match each definition to one of the following items. -Modifiers of the main term that have an effect on the appropriate code choice

Match each definition to one of the following items. -The reason, in the patient's own words, for coming to the hospital

What is the main term in "aspiration pneumonia"?

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

Match each definition to one of the following items. -Emergency Room

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

After a code has been selected from the Alphabetic Index to Diseases, what is the next step?

Match each definition to one of the following items. -After a code has been selected from the Alphabetic Index, it must be verified in this

The main terms usually are nouns and/or disease conditions.

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

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

What is the subterm in "aspiration pneumonia"?

Match each definition to one of the following items. -Provides advice on how to correctly code specific diagnoses

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 Neurodevelopmental 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 System

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

Filters