Exam 27: Inpatient Coding

The principal diagnosis is defined as the most serious condition during a patient's hospital stay.

A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.

The Tabular List of ICD-10-PCS contains grids that represent the last four characters of a procedure code.

It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."

In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary. The aspiration pneumonia is coded as if it exists.

The root operation that is defined as freeing of a body part is:

The acronym UHDDS stands for:

The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis. Which diagnoses should be reported?

In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.

Patient is admitted for a lobectomy for cancer of the lung. The patient was noted to be wheezing so the surgery was canceled because of an exacerbation of the patient's COPD.

In the inpatient setting, a procedure code from ICD-10-PCS would be assigned to identify a procedure.