NURSING MISC Flash cards and Lessons

1. Question: A word or phrase used by a physician to identify a disease from which an individual suffers Answer: Diagnosis 2. Question: A term or a series of terms that appear in parentheses following the main term or the subterm, the presence or absence of which has no effect on the selection of the codes listed for that main term Answer: Nonessential Modifier 3. Question: An indicator used to differentiate between a condition that developed during a particular hospital encounter and a condition present at the time of admission Answer: Present on Admission 4. Question: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Answer: Principal Diagnosis 5. Question: Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service Answer: Medical Necessity 6. Question: The procedure performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication Answer: Principal Procedure 7. Question: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay Answer: Other Diagnosis 8. Question: A procedure that is surgical in nature or carries a procedural or anesthetic risk or requires specialized training Answer: Significant Procedure 9. Question: Organizations that contract with Medicare to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients receive the right care at the right time Answer: Quality Improvement Organization 10. Question: Organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claim to detect and correct improper payments Answer: Recovery Audit Contractors 11. Question: Entries in the Alphabetic Index to Disease and Injuries that represent diseases, conditions, nouns, and adjectives Answer: Main Term 12. Question: A system for grouping similar disease and procedures and organizing related information for easy storage and retrieval Answer: Classification System 13. Question: A system of names that are used as preferred terminology Answer: Nomenclature 14. Question: The transformation of verbal descriptions into numbers; the process of assigning numeric or alphanumeric representations to clinical documentation Answer: Coding 15. Question: An additional diagnosis that describes a pre-existing condition that, because of its presence with a specific principal diagnosis, will cause an increase in the patient’s length of stay Answer: Comorbidity 16. Question: An additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifies the course of the patient’s illness or medical care required Answer: Complication 17. Question: Note that indicates that the conditions listed after it cannot ever be used at the same time as the code above the note Answer: Excludes1 18. Question: Note that means that two codes are applied when both conditions are present Answer: Excludes2 19. Question: A cross reference term in the Alphabetic Index that provides direction to look elsewhere in the Index before assigning a code Answer: See 20. Question: Suggests that there may be another main term in the Alphabetic Index that may also be referenced to provide additional Alphabetic Index entries that may be useful Answer: See Also 21. Question: Two codes may be required to fully describe a condition, but this note does not provide sequencing direction. Answer: Code Also 22. Question: Method of payment by Medicare for inpatient acute care hospital services, based on Medicare Severity Diagnosis-Related Groups (MS-DRGs) Answer: Inpatient Prospective Payment System Question: Adenocarcinoma of descending colon with extension to mesenteric lymph nodes. Answer: C18.6, C77.2 (Rationale: Adenocarcinoma—see neoplasm, malignant, by site. Go to Table of Neoplasms, intestine, large, colon, descending, malignant, and primary. Table of Neoplasms, lymph, gland, mesenteric, malignant, and secondary) 2. Question: Gangrene of lower leg due to uncontrolled type I diabetes. Answer: E10.52, E10.65 (Rationale: Diabetes, type 1, with, gangrene. Diabetes, out of control—code to Diabetes, by type, with hyperglycemia: Diabetes, type 1, with hyperglycemia) 3. Question: Iron deficiency anemia due to chronic blood loss. Answer: D50.0(Rationale: Anemia, iron deficiency, secondary to blood loss (chronic)) 4. Question: Lyme disease with associated arthritis. Answer: A69.23 (Rationale: Arthritis, due to or associated with, Lyme Disease) 5. Question: Diabetic hypoglycemic coma in a patient with uncontrolled type 1 diabetes. Answer: E10.641, E10.65 (Rationale: Diabetes, type 1, hypoglycemic, with coma, Diabetes, type 1, out of control (uncontrolled)—see Diabetes, by type (1), with hyperglycemia) 6. Question: Secondary thrombocytopenia due to hypersplenism. Answer: D69.59, D73.1 (Rationale: Thrombocytopenia, secondary. Hypersplenism) 7. Question: Chlamydial vaginitis. Answer: A56.02 (Rationale: Vaginitis, chlamydial) 8. Question: Infiltrating duct breast carcinoma, right upper outer quadrant, with metastases to bone (female patient). Answer: C50.411, C79.51 (Rationale: Neoplasm, breast, upper outer quadrant, malignant, primary, female, right breast. Neoplasm, bone, malignant, secondary) 9. Question: Malignant lymphoma, undifferentiated Burkitt type, Intrathoracic. Answer: C83.72 (Rationale: Lymphoma, Burkitt) 10. Question: Patient admitted for her first round of antineoplastic chemotherapy after a total abdominal hysterectomy and salpingo-oophorectomy for right ovarian carcinoma with known metastases to intrapelvic lymph nodes. Answer: Z51.11, C56.1, C77.5 (Rationale: Chemotherapy (session) (for) neoplasm. Neopla