Chapter 18 Basics of Diagnostic coding

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diagnosis

In medical coding, assessment and diagnostic statement are synonymous with _________

encounter

______ is any contact between a patient and a provider for service.

assessment

The _____ is the physicians determination of what is or may be wrong with the patient based on the finding from the H&P.

Chief Complaint

The abbreviation "CC" is a statement in the patient's own words that descirbes why the person sought medical attention. The Letters "CC" stand for ___ _____.

manifestation

________ is the signs and symptoms of a disease.

Alphabetic Index

The ____ ______ list conditions, injuries, and diseases in alphabetical order by main terms, modifying terms, and subterms.

Ancillary diagnostic services

Services that support patient diagnoses are known as ____ _____ ______.

and/or

In the context of the ICD_9_CM, the word "and" should always be interpeted as_______

chapters

_____ are broad sections of the ICD-9-CM coding manual grouped by disease or illness.

Code also

___ ____ is used when one or more codes are necessary to identify a given condition.

coding

Converting verbal or written conditions into numeric and alphanumberic designations is called _______

Conventions

______ is the abbrevations, punctuation, symbols, instructional notations, and related entities that provide quidance to the medical assisstant or coder in selecting as accurate and specific code.

diagnosis

The determination of the nature of a disease, injury, or congenital defect is a ________

diagnostic statement

The _____ ______ is the information about the diagnosis or diagnoses of the patient which have been extracted from the medical documentation.

etiology

The cause of the disorder, a claim may be classified according to _______

Exclusion and Excludes

______terms are always written in italics, and the word ______ is often enclosed in a box to draw particular attention to these instructions.

History and Physical Examination

H&P or HPE is an acronym for _____ _____ ___________.

ICD-9-CM

_______ is the current system for classifying disease to facilitate collection of uniform and comparable health information, for statistical purposes, and for indexing medical records for data storage and retrieval.

Prinicipal Diagnosis

____ ______ is the initial identification of the condition or complaint the patient expresses in the outpatient medical setting.

see

The term ___ mustt always be followed and is found in the Alphabetic Index, volumes 2 and 3; it is a direction given to a coder to look in another place.

see also

______ is the direction given to the coder to look elsewhere if the main term or subterm for that entry are not sufficient for coding the information.

see category

____ is a direction given to the coder to see a specific category (3 digit code), This must always be followed

S-Subjective finding O-Obective findings A-assement P-plan for treatment

Soap notes are a system of charting that includes the following 4 things:

use additional code

The term __ _____ ___ appears only in volume 1 in those subdiviosns in which the user should add futher information by means of an additional code to give more complete picture of the diagnosis.

with, with mention of, and assiocated with

In the context of the ICD-9-CM, terms ___, __ ___ ___, and ____ ____ dictate that both parts of the title be present in the statemnet of the diagnosis in order to assign the particular code.

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