When a patient is discharged from the hospital without a confirmed diagnosis, the suspected conditions listed on the discharge summary are coded as if they were _blank_.confirmedThis source documentation is written by the admitting physician and explains the background and current issues used to make the decision to admit the patient into the hospital.History and physicalThe diagnosis in the documentation is known as the _blank_ in the coding process.whyMany diagnostic statements are made up of _blank_ words, with each providing additional information.multiplewhen might a diagnosis code be assigned that explains why the patient was seen but is not a current health condition or injury?Preventive care
Routine or administrative exams
ScreeningsOnly those conditions addressed by the provider during a(n) _blank_ encounter will be coded for reimbursement.specificThe _blank_ + the symptom = the diagnosis.signWhat is coded in an outpatient encounter if there is no confirmed diagnostic statement?Symptoms
SignsSelect the source documents that are in patients' records and used to abstract information for coding.History and physical
Registration form
Physician's notes
Operative reportsThe word that identifies the disease, illness, condition, or primary reason for the visit is also known as the _blank_ term.mainThe cause and effect relationship between the two conditions must be documented by the physicians and supported by medical research to be coded as a _blank_.manifestationWhat is a condition that is present in the same body at the same time as another problem or disease but is unrelated to that other condition?Co-morbidityWhen abstracting the documentation, you will need to identify signs and symptoms that are already part of the description of a(n) _blank_ diagnosis.confirmedA sequela is the residual impact of a _blank_ condition that may need the attention of a physician.previousWhat abstract details are only needed when reporting external causes?Where
HowIf another physician or health care provider referred a patient for a consultation, what source document is that information found on?Referral authorization formProcedures are what was _blank_ for the patient.doneA manifestation results from a(n) _blank_ condition.underlyingWhy would a coder need to query a provider?Information is missing
Information is inconsistent
Information is contradictoryIf a patient is injured, the how and where the patient became injured are known as _blank_ causes.externalThe law does not permit the coder to _blank_ or promote a specific response from the physician.promptWhen querying the physician for more details, the coder must get the response in _blank_.writing
