CDIP Domain 1: Clinical Coding Practice Exam

CDIP Domain 1: Clinical Coding Practice Exam Coding Clinic - answerValuable reference tool for coders that is published by AHA each quarter CPT - answerCurrent Procedural Terminology MS-DRGs - answerMedicare Severity-Diagnosis Related Groups CPT Assistant - answerMonthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - answerProvides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - answerProvides 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 - answerProvide 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 - answerSummarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - answerProvides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body Encoder - answerSpecialty 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? - answerIt 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 - answerDiagnosis that, after study, is the reason for the patient's admission to the hospital.