Chapter 12 basics of diagnostic coding
Terms in this set (17)
The determination of the nature of a disease, injury, or congenital defect is a(n)
_____ is any contact between a patient and a provider of service.
_____ is an indication of presence of an illness
The ______ lists diagnostic terms and related codes in alphabetical order by main terms.
are broad sections of the ICD-10-CM coding manual grouped by disease and injuries.
Converting oral or written descriptions into alphanumeric designations is called _____.
refers to the abbreviations, punctuation, symbols, instructional notations, and related entities that help the medical assistant or coder select an accurate and specific code.
The ____ is the information about the diagnosis or diagnoses of the patient that has been extracted from the medical documentation.
History & Physical Examination
H&P stands for _____.
_____ is the system currently used in the United States for classifying disease to facilitate the collection of statistical data.
: Chief complaint, history of patient illness.
: vital signs, physical examination
Plan of Treatment
: x-ray, pathology, lab work
The term ____ is found at the etiology code so that the underlying condition is sequenced first followed by the manifestation.
General Equivalence Mapping
_____ are used to map ICD-9-CM codes to the current ICD-10-CM diagnostic codes.
To prepare for medical coding, the coder must analyze the patient's health record and ____ the diagnostic statement.
The coder must look up codes in the _______ first before assigning the code.
The coder can use the ______ to code tumors, either malignant or benign.
Number of fetus
The seventh character in obstetrics coding is used to identify the _______.