coding exam| 110 QUESTIONS| WITH COMPLETE SOLUTIONS

What term does the Table of Drugs and Chemicals use to describe poisoning that results from an inadvertent overdose, wrong substance administered/taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alcohol? Correct Answer: Accidental (Unintentional) When coders have questions about documented diagnoses or procedures/services, they use a physician query process to contact the responsible physician to __________. Correct Answer: request clarification about documentation and the code(s) to be assigned The primary purpose of the patient record is to provide for _____. Correct Answer: patient continuity of care Which is an electronic database and universal standard that is used to identify medical laboratory observations for the purpose of clinical care and management? Correct Answer: LOINC Integrating the __________ physician query process with the electronic health record allows physicians to more easily receive and reply to queries Correct Answer: automated In a source-oriented record, reports are organized according to __________ in labeled sections. Correct Answer: documentation source Which is a systematic method of documentation that consists of four components: database, initial plan, problem list, and progress notes? Correct Answer: problem-oriented record To learn more about specific medications, goals, procedures, therapies, and treatments used to treat the patient, review the __________ plans in the problem-oriented record. Correct Answer: therapeutic ICD-10-CM index subterms are indented __________ spaces below main terms. Correct Answer: 2 When patient record documentation is insufficient to assign a more specific code, a(n) __________ code is assigned. Correct Answer: unspecified In this ICD-10-CM index entry, "adrenal (capsule) (cortex) (gland) E27.8" is a __________. Correct Answer: subterm Which are used in the ICD-10-CM Tabular List of Diseases and Injuries to enclose abbreviations, synonyms, alternative wording, or explanatory phrases? Correct Answer: brackets Boxed notes in the ICD-10-CM Index to Di