Clinical Coding Theory - NCCQ
Revision
What is the definition of clinical coding? - ANS>>Clinical coding is the
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translation of medical terminology that describes a patient's complaint, problem,
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diagnosis, treatment or other reason for seeking medical attention into codes
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that
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can then be easily tabulated, aggregated and sorted for statistical analysis in an
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efficient and meaningful manner.
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What is meant by 'coding uniformity'? - ANS>>Coding uniformity means that
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whenever a given condition or reason for an episode is coded, the same code
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is always used to represent that condition or reason for the encounter.
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List the three Volumes of ICD-10 - ANS>>Volume 1: Tabular List
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Volume 2: Instruction Manual
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Volume 3: Alphabetical Index
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List three sections included in Volume 2 of ICD-10 - ANS>>1. Introduction
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2. Description of the ICD
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3. How to use the ICD
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4. Rules and guidelines for mortality and morbidity coding
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5. Statistical presentation
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6. History of the development of the ICD
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7. Annexes
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How many chapters does ICD-10 Tabular List contain? - ANS>>22 chapters
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Name the three types of chapters included in the ICD-10 Tabular List -
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ANS>>Body system chapters
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Special group chapters
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Other chapters ww
What is step three of the ICD-10 Four Step Coding Process? - ANS>>Assign a
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tentative code(s) using the Alphabetical Index and taking into account all rules,
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conventions and standards.
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In what three circumstances are supplementary fifth characters used in ICD-10
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Chapter XIX Injury, poisoning and certain other consequences of external
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causes? - ANS>>Supplementary fifth characters are used in this chapter to
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identify open and closed fractures, intracranial injuries with or without open
ww ww ww ww ww ww ww ww ww ww ww
intracranial wound and internal injuries with or without open wound into cavity.
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, List the three types of standard included in the National Clinical Coding
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Standards ICD-10 5th Edition for Morbidity Coding - ANS>>General Coding
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Standards
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Chapter Standards ww
Coding Standards ww
What are the three dimensions of coding accuracy and what do they mean? -
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ANS>>Individual codes:
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Each clinical statement of diagnosis must have the correct code assignment. An
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individual patient may have many diagnoses (or procedures). Consequently, a
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coded record for an episode will have at least one or potentially many
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individual codes.
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Totality of codes: ww ww
It means that all codes necessary to give an accurate clinical picture of the
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wwpatient's diagnosis, problems or other reasons for an episode encounter, must
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wwbe assigned in accordance with the rules, conventions and standards of the
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wwclassification. ww
Sequencing of codes: ww ww
Codes must be sequenced in accordance with clinical coding standards to
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provide consistent data for statistical analysis. A significant aspect of
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sequencing is the selection of the main condition treated.
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What time period is the perinatal period as regarded in the National Clinical
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Coding Standards reference book? - ANS>>Before birth through to the 27th
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day, 23rd hour and 59th minute of life i.e. the period before the start of the
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28th day.
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How must the term "if desired" in an instructional note be interpreted by the
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coder? - ANS>>Where a note states to "Use an additional code, if desired" to
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add further information about the disorder, where that information is present in
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the medical record the additional code must be assigned.
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Name and define the two cross-references found in the ICD-10 Alphabetical
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Index - ANS>>See:
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This is an explicit direction to look elsewhere as no codes can be found
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alongside this cross reference. It is used to direct the coder to another lead
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term in the Alphabetical Index where complete information can be found. It is
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also used after anatomical sites to remind the coder that the Alphabetical
ww ww ww ww ww ww ww ww ww ww ww ww
Index is organised by condition.
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See also: ww
This is a reminder to look under another lead term if the term the coder is
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looking for cannot be found modified in any way under the first lead term.
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Revision
What is the definition of clinical coding? - ANS>>Clinical coding is the
ww ww ww ww ww ww ww ww ww ww ww
translation of medical terminology that describes a patient's complaint, problem,
ww ww ww ww ww ww ww ww ww ww
diagnosis, treatment or other reason for seeking medical attention into codes
ww ww ww ww ww ww ww ww ww ww ww
that
ww
can then be easily tabulated, aggregated and sorted for statistical analysis in an
ww ww ww ww ww ww ww ww ww ww ww ww
efficient and meaningful manner.
ww ww ww ww
What is meant by 'coding uniformity'? - ANS>>Coding uniformity means that
ww ww ww ww ww ww ww ww ww ww
whenever a given condition or reason for an episode is coded, the same code
ww ww ww ww ww ww ww ww ww ww ww ww ww ww
is always used to represent that condition or reason for the encounter.
ww ww ww ww ww ww ww ww ww ww ww ww
List the three Volumes of ICD-10 - ANS>>Volume 1: Tabular List
ww ww ww ww ww ww ww ww ww ww ww
Volume 2: Instruction Manual
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Volume 3: Alphabetical Index
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List three sections included in Volume 2 of ICD-10 - ANS>>1. Introduction
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2. Description of the ICD
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3. How to use the ICD
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4. Rules and guidelines for mortality and morbidity coding
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5. Statistical presentation
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6. History of the development of the ICD
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7. Annexes
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How many chapters does ICD-10 Tabular List contain? - ANS>>22 chapters
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Name the three types of chapters included in the ICD-10 Tabular List -
ww ww ww ww ww ww ww ww ww ww ww ww
ANS>>Body system chapters
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Special group chapters
ww ww
Other chapters ww
What is step three of the ICD-10 Four Step Coding Process? - ANS>>Assign a
ww ww ww ww ww ww ww ww ww ww ww ww ww
tentative code(s) using the Alphabetical Index and taking into account all rules,
ww ww ww ww ww ww ww ww ww ww ww ww
conventions and standards.
ww ww ww
In what three circumstances are supplementary fifth characters used in ICD-10
ww ww ww ww ww ww ww ww ww ww
Chapter XIX Injury, poisoning and certain other consequences of external
ww ww ww ww ww ww ww ww ww ww
causes? - ANS>>Supplementary fifth characters are used in this chapter to
ww ww ww ww ww ww ww ww ww ww ww
identify open and closed fractures, intracranial injuries with or without open
ww ww ww ww ww ww ww ww ww ww ww
intracranial wound and internal injuries with or without open wound into cavity.
ww ww ww ww ww ww ww ww ww ww ww ww
, List the three types of standard included in the National Clinical Coding
ww ww ww ww ww ww ww ww ww ww ww
Standards ICD-10 5th Edition for Morbidity Coding - ANS>>General Coding
ww ww ww ww ww ww ww ww ww ww
Standards
ww
Chapter Standards ww
Coding Standards ww
What are the three dimensions of coding accuracy and what do they mean? -
ww ww ww ww ww ww ww ww ww ww ww ww ww
ANS>>Individual codes:
ww ww
Each clinical statement of diagnosis must have the correct code assignment. An
ww ww ww ww ww ww ww ww ww ww ww
individual patient may have many diagnoses (or procedures). Consequently, a
ww ww ww ww ww ww ww ww ww ww
coded record for an episode will have at least one or potentially many
ww ww ww ww ww ww ww ww ww ww ww ww ww
individual codes.
ww ww
Totality of codes: ww ww
It means that all codes necessary to give an accurate clinical picture of the
ww ww ww ww ww ww ww ww ww ww ww ww ww
wwpatient's diagnosis, problems or other reasons for an episode encounter, must
ww ww ww ww ww ww ww ww ww ww
wwbe assigned in accordance with the rules, conventions and standards of the
ww ww ww ww ww ww ww ww ww ww ww
wwclassification. ww
Sequencing of codes: ww ww
Codes must be sequenced in accordance with clinical coding standards to
ww ww ww ww ww ww ww ww ww ww
provide consistent data for statistical analysis. A significant aspect of
ww ww ww ww ww ww ww ww ww ww
sequencing is the selection of the main condition treated.
ww ww ww ww ww ww ww ww ww
What time period is the perinatal period as regarded in the National Clinical
ww ww ww ww ww ww ww ww ww ww ww ww
Coding Standards reference book? - ANS>>Before birth through to the 27th
ww ww ww ww ww ww ww ww ww ww ww
day, 23rd hour and 59th minute of life i.e. the period before the start of the
ww ww ww ww ww ww ww ww ww ww ww ww ww ww ww ww
28th day.
ww ww
How must the term "if desired" in an instructional note be interpreted by the
ww ww ww ww ww ww ww ww ww ww ww ww ww
coder? - ANS>>Where a note states to "Use an additional code, if desired" to
ww ww ww ww ww ww ww ww ww ww ww ww ww ww
add further information about the disorder, where that information is present in
ww ww ww ww ww ww ww ww ww ww ww ww
the medical record the additional code must be assigned.
ww ww ww ww ww ww ww ww ww
Name and define the two cross-references found in the ICD-10 Alphabetical
ww ww ww ww ww ww ww ww ww ww
Index - ANS>>See:
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This is an explicit direction to look elsewhere as no codes can be found
ww ww ww ww ww ww ww ww ww ww ww ww ww
alongside this cross reference. It is used to direct the coder to another lead
ww ww ww ww ww ww ww ww ww ww ww ww ww ww
term in the Alphabetical Index where complete information can be found. It is
ww ww ww ww ww ww ww ww ww ww ww ww ww
also used after anatomical sites to remind the coder that the Alphabetical
ww ww ww ww ww ww ww ww ww ww ww ww
Index is organised by condition.
ww ww ww ww ww
See also: ww
This is a reminder to look under another lead term if the term the coder is
ww ww ww ww ww ww ww ww ww ww ww ww ww ww ww
looking for cannot be found modified in any way under the first lead term.
ww ww ww ww ww ww ww ww ww ww ww ww ww ww