D521-Introduction to Medical Coding
What was the first ICD revision for which an alternate was made due to disagreements?
- ✔️✔️The United States developed its own version of ICD-8 based on disagreements
over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM? - ✔️✔️No
diagnostic information is included.
American Health Information Management Association (AHIMA) - ✔️✔️a professional
organization for health information management (HIM) professionals
Diagnosis - ✔️✔️identification of a disease by a licensed provider
Morbidity - ✔️✔️Refers to ill health in an individual and the levels of ill health in a
population or group.
Mortality - ✔️✔️the state of being subject to death
Comorbidity - ✔️✔️a secondary condition that is present on admission and causes an
increase in length of stay (LOS)
Complication - ✔️✔️a secondary condition that arises during hospitalization and
causes an increase in length of stay (LOS)
Principal diagnosis - ✔️✔️that condition established after study, which is found to be
primarily responsible for admission of the patient to the hospital
What is a characteristic of ICD-6? - ✔️✔️The first version of ICD used for both death
classification and disease indexing
American Hospital Association (AHA) - ✔️✔️Non profit group or alliance of member
hospitals and health care organizations that promote the interests of hospitals. It is an
advocacy group for health care organizations, particularly hospitals
World Health Organization (WHO) - ✔️✔️A group within the United Nations responsible
for human health, including combating the spread of infectious diseases and health
issues related to natural disasters.
History of Present Illness (HPI) - ✔️✔️eight categories that constitute a chronological
description of an illness.
, History of Present Illness (HPI) eight categories - ✔️✔️How long have you had the sore
throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors - ✔️✔️Illegible physician handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
Hybrid Record - ✔️✔️A combination of paper and electronic records; a health record
that includes both paper and electronic elements
Integrated health record - ✔️✔️A system of health record organization in which all the
paper forms are arranged in strict chronological order and mixed with forms created by
different departments
The Joint Commission - ✔️✔️an independent organization that accredits healthcare
organizations in the United States based on performance standards
Longitudinal health record - ✔️✔️a single complete health record that combines data
from a variety of sources within a healthcare system
What was the first ICD revision for which an alternate was made due to disagreements?
- ✔️✔️The United States developed its own version of ICD-8 based on disagreements
over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM? - ✔️✔️No
diagnostic information is included.
American Health Information Management Association (AHIMA) - ✔️✔️a professional
organization for health information management (HIM) professionals
Diagnosis - ✔️✔️identification of a disease by a licensed provider
Morbidity - ✔️✔️Refers to ill health in an individual and the levels of ill health in a
population or group.
Mortality - ✔️✔️the state of being subject to death
Comorbidity - ✔️✔️a secondary condition that is present on admission and causes an
increase in length of stay (LOS)
Complication - ✔️✔️a secondary condition that arises during hospitalization and
causes an increase in length of stay (LOS)
Principal diagnosis - ✔️✔️that condition established after study, which is found to be
primarily responsible for admission of the patient to the hospital
What is a characteristic of ICD-6? - ✔️✔️The first version of ICD used for both death
classification and disease indexing
American Hospital Association (AHA) - ✔️✔️Non profit group or alliance of member
hospitals and health care organizations that promote the interests of hospitals. It is an
advocacy group for health care organizations, particularly hospitals
World Health Organization (WHO) - ✔️✔️A group within the United Nations responsible
for human health, including combating the spread of infectious diseases and health
issues related to natural disasters.
History of Present Illness (HPI) - ✔️✔️eight categories that constitute a chronological
description of an illness.
, History of Present Illness (HPI) eight categories - ✔️✔️How long have you had the sore
throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors - ✔️✔️Illegible physician handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
Hybrid Record - ✔️✔️A combination of paper and electronic records; a health record
that includes both paper and electronic elements
Integrated health record - ✔️✔️A system of health record organization in which all the
paper forms are arranged in strict chronological order and mixed with forms created by
different departments
The Joint Commission - ✔️✔️an independent organization that accredits healthcare
organizations in the United States based on performance standards
Longitudinal health record - ✔️✔️a single complete health record that combines data
from a variety of sources within a healthcare system
