ICD 10 CA Coding Theory Questions With Correct Answers Already Passed!!

Clinical reference terminologies - 1. A set of standardized terms and their synonyms that record patient findings, circumstances, events and interventions 2. It supports clinical care;, decision support, outcome research, and quality improvement 3. It provides a means to record clinical data 4. An example is SNOMED "A collection of terms used to support user entry of health information into computerized clinical applications by ensuring consistent data entry that links to current and historical data" - Interface terminology SNOMED CT concepts are organized into ____ hierarchies. - 19 SNOMED CT hierarchies - Diseases and interventions Diagnoses and symptoms Medications and family history Devices and findings 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. - Granularities RAI is described as - Used as an assessment tool to document characteristics of residents Classification used in Canada to collect data on interventions - CCI The clinical health care terminology composed of concepts and terms, where the concepts are linked to one another by relationships - SNOMEDRefers to clinical data - Diagnoses and Interventions A ____________ is a recognized system of terms used in a science or art that follows pre-established naming of conventions. - Nomenclature A ______________ is a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures. - Classification List three factors that impact data quality - Being able to audits the coded data Lack of training or experience CIHI coding standards not being followed Access to resources and references Completeness of the documentation What is coding? - The process of assigning an alphanumeric code to diagnostic and intervention data. Clinical Data - Includes diagnoses and interventions