10/6/13 Flashcards about Coding Test 1

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Coding Test 1
MEdical coding - exam 1 Intro
Question Answer
Nomenclature systematic listing of proper names
Classification grouping together of similar items
Nomenclature of
Diseases and
Operations
Diseases classified according to both anatomical location and the
etiology, or cause.
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.
Purpose of coding: confidentiality, communicate differently, statistics
Define: ICD-9-CM
international classification of diseases 9th revision, clinical
modifications
Volume I is: Tabular List of diseases
Volume II is: Alphabetical Index of diseases
Volume III is: Tabular list and alphabetical index of procedures
Volume I has what
major subdivisions?
Classification of diseases and injuries, supplementary classifications (V
& E codes), Appendices
V codes are:
used to diagnose when there is no problem or conditions (Ex. routine
exam)
E codes are:
used to diagnose the environment of injury (Ex. weather, external
details)
Volume I has how
many chapters?
17 chapters that classify conditions according to etiology or by specific
anatomical system.
etiology: cause or reason for
Volume I is
structured by:
sections, categories, subcategories
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)
Categories consist
of:
3 digit category representing a single disease entity or a group of
similar or closely related condition. (Ex. 520)
Subcategories
4th digits that provide more specificity or information regarding the
etiology, the site, or manifestation. Fourth digit subcategories are
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consist of: collapsable to the 3 digit code level. A 3 digit code cannot be assigned
if a category has been subdivided.
Fifth digit
classifications:
provide even greater specificity.
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.
Supplementary
classifications are:
V and E codes
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)
E codes are written
as:
The letter E followed by 3 numeric digits, a decimal, and a fourth digit.
(Ex. E357.2)
Morphology: the tissue or body system or organ involved where cancer is prevalent
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)
Volume II Index:
includes terminology for all codes. 3 levels of index include main term,
subterm, carryover lines.
Main term: represents diseases. could be a condition; noun; adjective.
Subterm aka modifier
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.
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.
"With" and "without"
are listed where?
Beginning of all subterms rather than in alphabetical order.
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.
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.
eponym: name of something named after the person who discovered it, etc.
How many index
tables are there in
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the alphabetic
index?
2
What are the 2 index
tables in the
alphabetic index?
hypertension table and neoplasm table
conventions aka: directions
What are
conventions:
cross reference terms that are directions to look elsewhere before
assigning a code.
Instructional
notations:
clarify information or provide additional information. (Ex. include and
exclude notes)
Notes:
Instructions to assign a 5th digit, additional coding instructions, define
terms, appear in all 3 volumes.
How do notes
appear in the
alphabetic index?
Boxed, set italic type
How do notes
appear in the tabular
list?
located various levels and are not boxed.
What is multiple
coding?
Situation where more than one code is needed to describe the
condition.
What are the 2 types
of multiple coding?
Mandatory and indescriminate.
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.
In alphabetic index
where is the second
code listed for
mandatory coding?
In brackets.
Indiscriminate
multiple coding:
Irrelevent medical information such as signs and symptoms.
If additional code
appears at
beginning of a
chapter:
It affects entire chapter.
connecting words:
subterms that indicate a relationship between the main terms and an
associated condition or etiology in alphabetic index.
NEC not elsewhere classified
NOS not otherwise specified
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sechon mark: indicates presence of footnotes
lozenge: used for research purposes only
parenthesis:
enclose supplementary words or explanatory information that may or
may not be present in the statement of a diagnosis or procedure.
square brackets:
used to enclose synonyms, alternative wording, abbreviations and
explanatory phrases.
slanted brackets:
found only in alphabetic index, enclose a code number that must be
used in conjunction witha code immediately preceeding it
colon:
used in tabular list after an incomplete term that needs one or more
modifiers in order to assign a given category or code.
brace:
simplifies tabular list entries and saves printing space by reducing
repetitive wording.
manifestation: resulting condition
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.
Created by: concubine on 2005-03-11