Question 1

Match the following with the correct term or definition.
-When a patient displays a symptom that could represent a variety of 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 G

Question 2

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 D

Question 3

Match the following with the correct term or definition.
-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 C

Question 4

Match the following with the correct term or definition.
-Once 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 5

What is the main term in the procedure "vaginal hysterectomy"?

Accepted Answer

A) Vaginal 
B) Hysterectomy 
C) Vaginal hysterectomy 
D) None of the above 
A) Vaginal 
B) Hysterectomy 
C) Vaginal hysterectomy 
D) None of the above

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

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 8

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

Accepted Answer

It must be

Question 9

What is the subterm in "infantile eczema"?

Accepted Answer

The answer of What is the subterm in "infantile eczema"?...

Question 10

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

Question 11

What is the subterm in "aspiration pneumonia"?

Accepted Answer

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

Question 12

Match the following with the correct term or definition.
-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 13

Match the following with the correct term or definition.
-Synopsis of the events of a patient's hospital encounter

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 14

The main term for procedures in ICD-10-CM is identified by the ____.

Accepted Answer

A) anatomic site 
B) place of incision 
C) procedure performed 
D) none of the above are correct 
A) anatomic site 
B) place of incision 
C) procedure performed 
D) none of the above are correct

Question 15

The __________,if available,is the first step in the process of record review for code selection.

Accepted Answer

The answer of The __________,if available,is the first step in...

Question 16

The admitting diagnosis is usually a sign or a symptom.

Accepted Answer

A) True 
 B)False

Question 17

The main term in "aplastic anemia" is ____.

Accepted Answer

A) anemia 
B) aplasia 
C) aplastic 
D) none of the above 
A) anemia 
B) aplasia 
C) aplastic 
D) none of the above

Question 18

Match the following with the correct term or definition.
-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 19

What is the subterm in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the subterm in "rheumatoid arthritis"?...

Question 20

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

Accepted Answer

A) True 
 B)False

Exam 4: Basic Steps of Coding

Match the following with the correct term or definition. -When a patient displays a symptom that could represent a variety of diagnoses

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

Match the following with the correct term or definition. -Modifiers of the main term that have an effect on the appropriate code choice

Match the following with the correct term or definition. -Once a code has been selected from the Alphabetic Index,it must be verified in this

What is the main term in the procedure "vaginal hysterectomy"?

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

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

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

What is the subterm in "infantile eczema"?

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 subterm in "aspiration pneumonia"?

Match the following with the correct term or definition. -A cross-reference instruction in the code book

Match the following with the correct term or definition. -Synopsis of the events of a patient's hospital encounter

The main term for procedures in ICD-10-CM is identified by the ____.

The __________,if available,is the first step in the process of record review for code selection.

The admitting diagnosis is usually a sign or a symptom.

The main term in "aplastic anemia" is ____.

Match the following with the correct term or definition. -Review the health record

What is the subterm in "rheumatoid arthritis"?

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

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

General Coding Guidelines for Medical and Surgical Procedures

General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary 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 Neuro developmental 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 Tissue

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

Reimbursement Methodologies

Out patient Coding

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