CDIP Domain 1: Clinical Coding Practice EXAM WITH 100% CORRECT ANSWERS

Coding Clinic Valuable reference tool for coders that is published by AHA each quarter CPT Current Procedural Terminology MS-DRGs Medicare Severity-Diagnosis Related Groups CPT Assistant Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical Provides the initial chief complaint and initial impressions of the provider when the patient is first admitted. It also has a comprehensive physical review of the patient's body systems and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to treat the patient. Progress Notes Provide information about what is going on with the patient on a day-to-day basis; they should include the diagnoses that are being treated as well as any information about any changes in the patient's well-being and tests/procedures being performed. Operative and Pathology Reports Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body Encoder Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system What is the value of utilizing coding software? It facilitates accurate coding by providing links to coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with additional information for the coder to consider when placing codes into the encoder Principal diagnosis Diagnosis that, after study, is the reason for the patient's admission to the hospital. Secondary diagnoses Additional supporting information for the conditions the patient is being cared for MCC Major Complication or Comorbidity