NCCQ theory ICD10
What is clinical coding? - ANS>>Clinical coding is the translation of medical terminology
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that describes a patient's complaint, problem, diagnosis, treatment or other reason for
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seeking medical attention into codes that can then be easily tabulated, aggregated and
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sorted for statistical analysis in an efficient and meaningful manner.
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What is coding uniformity and why is it important? - ANS>>Uniformity means that
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whenever a given condition or reason for an episode is coded, the same code is always
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used to represent that condition or reason for the encounter. Uniformity is essential if the
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information is to be useful and comparable
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What are the three dimensions of coding accuracy? - ANS>>Individual codes
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Totality of codes tt tt
Sequencing of codes tt tt
What is meant by Individual codes? - ANS>>Each clinical statement of diagnosis must
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have the correct code assignment. An individual patient may have many diagnoses (or
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procedures). Consequently a coded record for an episode will have at least one or
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potentially many individual codes.
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What is meant by totality of codes and why is this important? - ANS>>The concept of
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totality of codes is complex. It means that all codes necessary to give an accurate clinical
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picture of the patient's diagnosis, problems or other reasons for an episode encounter,
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must be assigned in accordance with the rules, conventions and standards of the
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classification. This is important as it is possible for a list of codes to describe an episode
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incorrectly in terms of clinical coding rules and standards even though the individual
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codes selected are correct.
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What is meant by sequencing of codes, why is this important and what is a significant
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aspect of this? - ANS>>Codes must be sequenced in accordance with clinical coding
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standards to 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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How many steps make up the coding process? - ANS>>Four
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What is step one of the four step coding process? - ANS>>Step One
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Analyse medical terminology to determine lead term(s) and modifier(s)
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What is step two of the four step coding process? - ANS>>Step Two
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Locate the lead term(s) in the Alphabetical Index (ICD-10 Volume 3)
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What is step three of the four step coding process? - ANS>>Step Three
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, Assign a tentative code(s) using the Alphabetical Index and taking into account all rules,
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conventions and standards.
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What is step four of the four step coding process? - ANS>>Step Four
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Verify the code(s) using the Tabular List (ICD-10 Volume 1) and taking into account
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instructional notes.
tt tt
If there is a doubt as to where a condition should be coded, what chapters must take
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priority? - ANS>>The 'special group' chapters must take priority.
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How many chapters make up ICD-10? - ANS>>22 chapters
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Name the types of chapters within ICD-10, describe briefly their content and give the
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chapter numbers that fall within each type. - ANS>>Special group chapters
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Chapters I-V, XV-XVII and XIX classify conditions that do not focus on any one body
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system. In general, conditions are primarily classified to one of the 'special group'
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chapters.
tt
Body system chapters tt tt
Chapters VI-XIV classify conditions according to the body system they affect.
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Other chapters tt
Chapters XVIII and XX-XXII classify other disorders and factors which do not sit
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comfortably in either a special group or body system chapter
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What character levels must code assignment be made to, within ICD-10, to make the code
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valid? - ANS>>Code assignment must always be made to four character level or five
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character level (where available and in line with fifth character coding standards), for the
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code to be valid
tt tt tt tt
Describe what must be done when a three character code does not have fourth character
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subdivisions and why this is. - ANS>>Where a three character category code is not
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subdivided into four character subdivisions the 'X' filler must be assigned in the fourth
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character field so the codes are of a standard length for data processing and validation.
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
The code is still considered a three character code from a classification perspective.
tt tt tt tt tt tt tt tt tt tt tt tt tt
Where a three character code requires assignment of both the 'X' filler and a fifth
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character subdivision, the 'X' filler must continue to be recorded in the fourth field before
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the fifth character.
tt tt tt
Why are cross reference provided in the ICD index? - ANS>>Cross references are
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provided in the Alphabetical Index to ensure that all possible terms or its synonyms are
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
referenced by the coder. Cross references explicitly direct the coder to other entries in the
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
index
tt
Name the two types of cross reference found within ICD-10 and describe their purpose. -
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ANS>>See
tt
This is an explicit direction to look elsewhere as no codes can be found alongside this
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
cross reference. It is used to direct the coder to another lead term in the Alphabetical
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
What is clinical coding? - ANS>>Clinical coding is the translation of medical terminology
tt tt tt tt tt tt tt tt tt tt tt tt
that describes a patient's complaint, problem, diagnosis, treatment or other reason for
tt tt tt tt tt tt tt tt tt tt tt tt
seeking medical attention into codes that can then be easily tabulated, aggregated and
tt tt tt tt tt tt tt tt tt tt tt tt tt
sorted for statistical analysis in an efficient and meaningful manner.
tt tt tt tt tt tt tt tt tt tt
What is coding uniformity and why is it important? - ANS>>Uniformity means that
tt tt tt tt tt tt tt tt tt tt tt tt
whenever a given condition or reason for an episode is coded, the same code is always
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
used to represent that condition or reason for the encounter. Uniformity is essential if the
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
information is to be useful and comparable
tt tt tt tt tt tt tt
What are the three dimensions of coding accuracy? - ANS>>Individual codes
tt tt tt tt tt tt tt tt tt tt
Totality of codes tt tt
Sequencing of codes tt tt
What is meant by Individual codes? - ANS>>Each clinical statement of diagnosis must
tt tt tt tt tt tt tt tt tt tt tt tt
have the correct code assignment. An individual patient may have many diagnoses (or
tt tt tt tt tt tt tt tt tt tt tt tt tt
procedures). Consequently a coded record for an episode will have at least one or
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
potentially many individual codes.
tt tt tt tt
What is meant by totality of codes and why is this important? - ANS>>The concept of
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
totality of codes is complex. It means that all codes necessary to give an accurate clinical
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
picture of the patient's diagnosis, problems or other reasons for an episode encounter,
tt tt tt tt tt tt tt tt tt tt tt tt tt
must be assigned in accordance with the rules, conventions and standards of the
tt tt tt tt tt tt tt tt tt tt tt tt tt
classification. This is important as it is possible for a list of codes to describe an episode
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
incorrectly in terms of clinical coding rules and standards even though the individual
tt tt tt tt tt tt tt tt tt tt tt tt tt
codes selected are correct.
tt tt tt tt
What is meant by sequencing of codes, why is this important and what is a significant
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
aspect of this? - ANS>>Codes must be sequenced in accordance with clinical coding
tt tt tt tt tt tt tt tt tt tt tt tt tt
standards to provide consistent data for statistical analysis. A significant aspect of
tt tt tt tt tt tt tt tt tt tt tt tt
sequencing is the selection of the main condition treated
tt tt tt tt tt tt tt tt tt
How many steps make up the coding process? - ANS>>Four
tt tt tt tt tt tt tt tt tt
What is step one of the four step coding process? - ANS>>Step One
tt tt tt tt tt tt tt tt tt tt tt tt
Analyse medical terminology to determine lead term(s) and modifier(s)
tt tt tt tt tt tt tt tt
What is step two of the four step coding process? - ANS>>Step Two
tt tt tt tt tt tt tt tt tt tt tt tt
Locate the lead term(s) in the Alphabetical Index (ICD-10 Volume 3)
tt tt tt tt tt tt tt tt tt tt
What is step three of the four step coding process? - ANS>>Step Three
tt tt tt tt tt tt tt tt tt tt tt tt
, Assign a tentative code(s) using the Alphabetical Index and taking into account all rules,
tt tt tt tt tt tt tt tt tt tt tt tt tt
conventions and standards.
tt tt tt
What is step four of the four step coding process? - ANS>>Step Four
tt tt tt tt tt tt tt tt tt tt tt tt
Verify the code(s) using the Tabular List (ICD-10 Volume 1) and taking into account
tt tt tt tt tt tt tt tt tt tt tt tt tt
instructional notes.
tt tt
If there is a doubt as to where a condition should be coded, what chapters must take
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
priority? - ANS>>The 'special group' chapters must take priority.
tt tt tt tt tt tt tt tt tt
How many chapters make up ICD-10? - ANS>>22 chapters
tt tt tt tt tt tt tt tt
Name the types of chapters within ICD-10, describe briefly their content and give the
tt tt tt tt tt tt tt tt tt tt tt tt tt
chapter numbers that fall within each type. - ANS>>Special group chapters
tt tt tt tt tt tt tt tt tt tt tt
Chapters I-V, XV-XVII and XIX classify conditions that do not focus on any one body
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
system. In general, conditions are primarily classified to one of the 'special group'
tt tt tt tt tt tt tt tt tt tt tt tt tt
chapters.
tt
Body system chapters tt tt
Chapters VI-XIV classify conditions according to the body system they affect.
tt tt tt tt tt tt tt tt tt tt
Other chapters tt
Chapters XVIII and XX-XXII classify other disorders and factors which do not sit
tt tt tt tt tt tt tt tt tt tt tt tt
comfortably in either a special group or body system chapter
tt tt tt tt tt tt tt tt tt tt
What character levels must code assignment be made to, within ICD-10, to make the code
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
valid? - ANS>>Code assignment must always be made to four character level or five
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
character level (where available and in line with fifth character coding standards), for the
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
code to be valid
tt tt tt tt
Describe what must be done when a three character code does not have fourth character
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
subdivisions and why this is. - ANS>>Where a three character category code is not
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
subdivided into four character subdivisions the 'X' filler must be assigned in the fourth
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
character field so the codes are of a standard length for data processing and validation.
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
The code is still considered a three character code from a classification perspective.
tt tt tt tt tt tt tt tt tt tt tt tt tt
Where a three character code requires assignment of both the 'X' filler and a fifth
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
character subdivision, the 'X' filler must continue to be recorded in the fourth field before
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
the fifth character.
tt tt tt
Why are cross reference provided in the ICD index? - ANS>>Cross references are
tt tt tt tt tt tt tt tt tt tt tt tt
provided in the Alphabetical Index to ensure that all possible terms or its synonyms are
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
referenced by the coder. Cross references explicitly direct the coder to other entries in the
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
index
tt
Name the two types of cross reference found within ICD-10 and describe their purpose. -
tt tt tt tt tt tt tt tt tt tt tt tt tt tt
ANS>>See
tt
This is an explicit direction to look elsewhere as no codes can be found alongside this
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
cross reference. It is used to direct the coder to another lead term in the Alphabetical
tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt tt
