Asthma is an example of a(n) ____________.
- diagnosis
- procedure
- indication
- opinion
Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in his or her notes. Use the best, most accurate code available based on that documentation.
Diagnosis: A physician’s determination of a patient’s condition, illness, or injury.
A patient complains of dizziness. The physician states that she has hypertension. You will:
- code for dizziness.
- code for hypertension.
- code for dizziness and hypertension.
- query the physician.
One of the reasons you, as a professional coding specialist, must learn about pathology and physiology is to distinguish between signs and symptoms that are included in a confirmed diagnosis and those that are not. Signs and symptoms that are integral to a confirmed diagnosis are not separately reported, whereas those that are included are coded separately.
Secondary Hypertension: The condition of hypertension caused by another condition or illness.
It is important for coders to understand:
- medical terminology.
- anatomy and physiology.
- the Physicians' Desk Reference.
- medical terminology and anatomy and physiology.
Professional coding specialists need to have a complete understanding of medical terminology in addition to the specifics of anatomy, etiology, and pathophysiology.
Dizziness is an example of a:
- symptom.
- sign.
- diagnosis.
- procedure.
A symptom is a subjective sensation as expressed by the patient and cannot be measured.
Symptom: A subjective sensation or departure from the norm as related by the patient.
If there is unclear information in the documentation, the coder should:
- code the diagnosis as though it existed.
- not code the diagnosis.
- query the physician.
- give the chart to the coding supervisor to code.
If there is unclear or missing information necessary to code the chart, the coder should query the physician for further clarification.
Physician’s Desk Reference (PDR): A series of reference books identifying all aspects of prescription and over-the-counter medications, as well as herbal remedies.
A professional coder should not:
- code any condition that has not been documented.
- send queries to the physician who cared for the patient.
- read the physician's notes thoroughly.
- code to the highest specificity.
You must code all conditions or complications that are relevant to the current encounter. One absolute rule for coders is "if it's not documented, it didn't happen!" So you can't code it.
Condition: A health-related situation.
What is the most important factor to consider when coding?
- Accuracy
- Productivity
- Timeliness
- All of these
The number one consideration when coding is accuracy.
The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should:
- code for pneumonia.
- code for chest congestion.
- query the physician.
- All of these
The guidelines in the Official ICD-10-CM Guidelines for Coding and Reporting will guide you toward the best, most accurate code and make coding decisions easier. Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, Subsection h states, “Do not code diagnoses documented as ‘probable’, ‘suspected’, ‘questionable’, ‘rule out’, or ‘working diagnosis.’ Rather, code the condition(s) to the highest degree of certainty for that encounter/visit.”
Pneumonia: An inflammation of the lungs.
The seven steps of accurate coding include:
- coding only documented conditions.
- coding the problems told to you by the nurse.
- coding only the chief complaint.
- coding the patient's history.
Never assume or try to guess. Code only what you know from actual documentation.
Condition: A health-related situation.
Justifying a procedure code with a diagnosis code is known as:
- medical necessity.
- the National Correct Coding Initiative.
- unbundling.
- upcoding.
Medical necessity is justifying the procedure, service, or treatment with a diagnosis to validate the reason for the procedure, service, or treatment.
Medical Necessity: The determination that the health care professional was acting according to standard practices in providing a particular procedure for an individual with a particular diagnosis. Also referred to as medically necessary.
A ________ code reports why the patient was seen by the physician.
- condition
- diagnosis
- procedure
- status
The diagnosis, or diagnostic statement, will explain why the patient was seen and treated.
Diagnosis: A physician’s determination of a patient’s condition, illness, or injury.
ICD-10-CM contains codes for reporting ______________.
- diagnoses
- payers
- systems
- treatments
ICD-10-CM is a directory of every diagnosis, sign, symptom, or other valid reason that could possibly be identified by a health care provider with regard to a patient encounter.
Diagnosis: A physician’s determination of a patient’s condition, illness, or injury.
The diagnosis code(s) ___________ the procedure provided to the patient during the encounter.
- cause
- justify
- explain
- document
The diagnosis codes that you assign justify the procedure, service, or treatment the health care professional provided to the patient during the encounter.
A diagnosis is a physician's determination of all of the following except a patient's:
- illness.
- injury.
- condition.
- procedure.
A physician's determination of a patient's condition, illness, or injury is known as the diagnosis.
Hypertension is an example of a ____________.
- symptom
- diagnosis
- procedure
- complaint
Hypertension is a diagnosis. High blood pressure is a sign because it can be measured with a sphygmomanometer (commonly referred to as a blood pressure cuff) and can be diagnosed.
A ____________ is a subjective sensation as expressed by the patient.
- symptom
- treatment
- diagnosis
- condition
A symptom is an indication of an abnormal state as described by the patient. There is no way to measure a symptom such as a headache or dizziness.
Symptom: A subjective sensation or departure from the norm as related by the patient.
A fever is an example of a(n) _________.
- sign
- objective
- sensation
- code
A sign is an indication of an abnormal state that can be measured. A patient's temperature can be measured with a thermometer.
Sign: Objective evidence of a disease or condition.
Diagnosis codes can report a disease, a sign, or a(n) ________.
- purpose
- treatment
- symptom
- objective
A symptom is an indication of an abnormal state as described by the patient. The physician's notes may include a diagnosis that identifies a specific condition or illness, the signs or symptoms of an unnamed problem, or another reason for the encounter.
Symptom: A subjective sensation or departure from the norm as related by the patient.
ICD-10-CM is an acronym for:
- International Classification of Diseases, Tenth Revision, Clinical Modification.
- International Classification of Diseases, Tenth Revision, Current Modification.
- International Classification of Diagnoses, Tenth Revision, Clinical Modification.
- International Classification of Diagnoses, Tenth Revision, Current Modification.
Modification. The acronym ICD-10-CM stands for International Classification of Diseases, Tenth Revision, Clinical Modification.
ICD-10-CM: The acronym for International Classification of Diseases, Tenth Revision, Clinical Modification.