A Diagnosis Type 6 is assigned to:
MP that requires treatment beyond maintenance of the preexisting condition; Increases the length of stay (LOS) by at least 24 hours
a designated asterisk code in a dagger asterisk convention when the condition it represents fulfills the requirements stated in the definition for Type M - Most Responsible Diagnosis
codes for symptoms or signs which are characteristic of the diagnosis
code conditions described as "ruled out."
A set of standardized terms and their synonyms that record patient findings, circumstances, events and interventions
Clinical reference terminologies
SNOMED CT concepts are organized into ____ hierarchies.
Which is not apart of the SNOMED CT hierarchies
Diseases and interventions
Diagnoses and symptoms
Devices and findings
Medications and Laboratory testings
Hierarchies have multiple____which allows information to be expressed with different levels of detail and precision which means data can be entered or retrieved depending on the need.
RAI is described as an assessment tool to document characteristics of residents
A Type 2 Diagnosis Type describes a condition that arises post-admission and satisfies the requirements for determining comorbidity and applies to both DAD and NACRS?
A ______________ is a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.
Is a classification that allows for the categorizing of patient reason for encounter designed to be used in a primary care setting
Is a multi-axial classification of categories used to collect psychiatric disorders and underlying conditions
ICD 10 CA
Includes gender, data of birth, and postal codes
inpatient records, ER records, and ambulatory records are examples of Source Documents
Includes those interventions that are through a needle or catheter
ENDOSCOPIC PER ORIFICE Approach
Describes a situation in which the intervention is terminated before an expected outcome is achieved
Interventions from this section are solely used for obstetrics and neonates
Section 3 and 5
Qualifiers (Field 4, 5, 6) describe the devices being used and related tissue and grafts.
This contains two characters and refers to "what is being done"
This coded to reflect the existence of a separate surgical wound which usually requires its own post-surgical care (example would be a free flap)
These are used to indicate quantitative measures related to the intervention
Select all the correct Interventions to Manage Bleeding
Composite of Codes in CCI describes a situation when one CCI code is not enough to describe the complex invention and requires an additional CCI code
This instruction is provided to also code associated factors in a condition such as infecting organism, underlying causes, asterisk code, to further describe a person's condition
Use Additional Code
This consists of numeric listing in code number order and is organized by chapter, blocks, and categories
NOS is given to code (s) to represent a condition or disease that has not been otherwise specialized
Dual Classification is a single code that classifies two conditions or a diagnosis with an associated secondary process (manifestation) or complication; a relationship exists between the two conditions
Secondary Term is located in the alphabetical index binocular, referring to the "modifiers" or anatomical site, the type of disease, injury or etiology
This represents a level of grouping between chapters and categories, an example would be: N60-N64
This can be at the fourth or fifth character of code and is used for "other" conditions (not specified)
Lead Term is located in the _____________________ binocular, using the name of the disease, injury or pathological condition
Table of Drugs
These conditions provide further information about conditions which are no longer present but are the cause of the current problem, often listed as "old, late effect, or due to previous"
Not elsewhere Classified
Uses the code Z21 when there is no documentation of an indicator disease from the National Surveillance case definition list.
This is known as a drug resistant bacteria
This can only be coded when documented by a physician and not on the basis of laboratory values alone
Must be used as a type 3 to identify patients who have been exposed to or had contact with AIDS/HIV
This term describes when the microbiology report may indicate the patient has MRSA, VRE on their body but the patient is not sick with the illness, these are coded to "carriers
Is used by physicians to describe a patient who presents with a fever, and the cause is not determined after investigations are completed
U82 - U85
This code must be assigned as a diagnosis type 1 or type 2 to describe organ failure as a result of severe sepsis
This describes when the healing process of a bone has not occurred and there is still separation of the bony structures involved in the fracture
This is often referred to as a THR where the femoral head and neck are replaced
This term is often referred to as herniation and/or protrusion of the intervertebral disc, and the condition may also be described as prolapsed disc or sequestrated disc.
This code is assigned as a MP when a patient returns to day surgery after the fracture has healed for removal of an internal fixation device such as a wire, pins or plate.
This describes a procedure which uses organ or tissue from an animal source
1.YM.79^^ CCI code is assigned together with the diagnosis code of Z41.1 when the patient is has no abnormality of their breast but is dissatisfied with their breast size
Pedicle flap uses a special balloon which is placed under the skin next to the area where the new tissue is needed to grow new skin for reconstruction
Pilonidal disease occurs in the sacrococcygeal region and can present as an abscess, a draining sinus or a fluctuating mass
This condition can result from an adverse effect of medication taken internally as directed and is assigned the code L27^
This condition can be described as either spontaneous or compression when involving the vertebrae, it occurs in bones weakened by pre-existing disease such as osteoporosis, Paget's disease and neoplasia
A patient arrived in hospital for an elective hip arthroplasty for osteoarthritis. Surgery was performed using a dual component THR without incident. On the third day the patient developed a wound infection resulting from the device inserted. Staphylococci were found on the cultures. The patient required to stay in hospital for another 3 days until the infection has cleared. What would be the MRDX?
The post-admit comorbidity diagnosis would be: non-mechanical complication of a joint prosthesis
Hip Arthroplasty for Osteoarthritis
The pre-admit comorbidity diagnosis would be: mechanical complication of a joint prosthesis
Hip arthroplastyusing dual component THR
A 17 year old male patient arrived in the emergency room with pain in his knee after falling down a hill yesterday while skiing at Blue Mountain. The patient had an x-ray of the knee indicated there was a ligament injury of the right knee. The patient was transferred to an inpatient bed and kept overnight awaiting surgery in the morning. What would be the main problem for the emergency visit?
Pain in the knee ligament
current injury of the knee ligament
X-ray of the knee ligament
old injury of the knee ligament
A female patient has developed cellulitis on her hand from an infected open wound which was caused by a cut from a garbage can. She is being treated with IV antibiotics for three days, and was discharged home. Which of the following would be the most responsible diagnosis?
cut from a garbage can
IV antibiotics treatment
cellulitis on the hand
open wound on the hand
An 77 year old male patient is admitted to treat degenerative arthritis of the right hip. On the history note it states the patient has diabetes type 2, hypertension and congestive heart failure. The patient was taken to the OR room where a THR was performed with excellent results. What would be the most responsible diagnosis?
Diabetes Type 2
A patient was admitted to hospital for a breast lumpectomy for infiltrating duct carcinoma. During the procedure the surgeon also removed all the axillary lymph nodes because of metastases. Post-op the patient had a chest tube inserted for pneumothorax. A CT scan of the chest performed before the patient was discharged indicated the pneumothorax had resided. What procedure would be sequenced first, also known as the principle procedure?
Chest tube for pneumothorax
CT Scan of the chest
Endoscopic per orifice pneumothorax
It is mandatory to assign the code Z51.1 and a CCI code for the administration of the pharmaceutical agent, plus a code from C00-C97 when a patient arrives in a hospital for the admission of:
This is a complication/side effect of cancer treatment, and can be a type 2 if it occurred during a patient's admission for initial treatment for cancer/or satisfies the criteria for a post-admit comorbidity
This is used as 5th digit for malignant secondary neoplasm
Bone rule state morphology to be intraosseous or odontogenic to be classified as a primary neoplasm
This information is necessary to capture if patients are requesting prophylactic surgery and is assigned the code Z80.-
Family hx of malignancy
Personal hx of malignancy
This term is used when the patient is described as having cancer that has spread to multiple secondary sites
Connective tissue tumors
When a patient is admitted for this type of treatment, a code for the malignant disease is assigned as the MRDX/MP
C80.0 code is used when certain tests such as CA 125 or PSA may be elevated but after investigation and/or observation shown the condition of cancer has been ruled out, so there is no condition to code.
An example of an intervention performed by an endoscopic approach would be:
A classification of categories used to collect psychiatric disorders and underlying conditions.
Select all that are found in section 2 of the CCI
What section of CCI would include MRI's, CT Scans and X-Rays?
There are ________ chapters in ICD 10 CA and __________ chapters in CCI.
19 chapters for CCI
23 chapters for ICD 10
19 chapters for ICD 10
23 chapters for CCI
A doctor has documented on the face sheet of an emergency record a condition of a fracture of the right femur due to a fall from a ladder. After examination of the record the x-ray results indicate a fracture of the proximal end of the femur. What should be coded as the MP based on the rule for specificity?
Fracture right femur
fracture of the proximal end of the femur
Fall from ladder
When coding sequelae of injuries the following rule applies:
Code the sequelae diagnosis as a diagnosis type 3 and the condition being treated as Type 1
Code the sequelae diagnosis as a diagnosis type 1 and the condition being treated as MRDX/MP
Only code the sequelae diagnosis
Code the sequelae diagnosis as a diagnosis OP and the condition being treated as Type 1
A 54 year old patient arrives in the emergency department complaining of coughing up blood. The emergency physician ordered a chest x-ray and a TB test. Results are pending at this time. An appointment was made for the patient to see a respirologist for the results of the test. The final diagnosis documented by the physician is hemoptysis and questionable TB of the lung. What would be could as the main problem?
Query Tuberculosis of the lung
Tuberculosis of the lung
A 38 year old female arrived in the emergency department with a laceration on her hand after falling from her patio. She has a past medical history of type 2 diabetes. The emergency physician sutured and dressing her wound under local anesthesia. The patient indicated she was feeling faint and a blood glucose tolerance test was performed indicating levels were higher than normal. The emergency physcian ordered her to be admitted to an inpatient bed for observation overnight to control her condition of diabetes. What would be the principal procedure for the ER visit?
blood glucose tolerance test
laceration on her hand
Suture of the laceration of the hand
A patient was admitted to hospital from the ER with a diagnosis of severe cough and the condition of impeding pneumonia. On the x-ray report done in the ER indicated the patient has severe bronchitis. The patient was given large doses of antibiotics. After 4 days in hospital the pneumonia was ruled out and the patient was discharged. The physician documents on the face sheet acute bronchitis. What code should the coder assign and the MRDX?
The following are correct when referring to a comorbidity
Are conditions that coexists at the time of admission and significantly affect the treatment received.
Require a consultation to assess a previously undiagnosed condition
Are conditions that increase the LOS by at least 24 hours.
Require a consultation to assess a previous undiagnosed condition
Is the building blocks of information, the raw facts and figures ( the elements, S01.90, V43.5, 1.YB.80.LA, 1811, F, age 47, outcome of visit - discharged home (D) or died (E)) - facts on their own have no meaning
Encoded data refers to transferring data into computer language, which can be stored into computer programs that can be transformed into meaningful health care information
Which of the following does not affect Data Quality?
International Health Terminology Standards Development Organization (IHTSDO) is a not-for-profit association that develops and
promotes use of SNOMED CT to support safe and effective health information exchange.
Which of the following is NOT an axis of Systematized Nomenclature of Pathology (SNOP)?
Morphology (pathologic anatomy...disease process)
Etiology (agents causing disease)
Function (functional disorders in the patho-physiological sense)
SNOMED CT concepts are organized into 19 hierarchies that includes
Semantic interoperability is the ability of computer systems to communicate (two systems will derive the same inferences from the same information)...basically to share
Data Quality is required to be maintained by going through the data periodically (select the following which applies).
Understanding the fundamental principles embodied within the knowledge, utilizing knowledge to make sense and have an insight of what is happening
A right breast neoplasm in the anatomical site of 5:00 would be given the code of _________