QUESTIONS WITH CORRECT ANSWERS.
What is clinical coding? correct answers Clinical coding is the translation of medical
terminology that describes a patient's complaint, problem, diagnosis, treatment or other reason
for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted
for statistical analysis in an efficient and meaningful manner.
What is coding uniformity and why is it important? correct answers Uniformity means that
whenever a given condition or reason for an episode is coded, the same code is always used to
represent that condition or reason for the encounter. Uniformity is essential if the information is
to be useful and comparable
What are the three dimensions of coding accuracy? correct answers Individual codes
Totality of codes
Sequencing of codes
What is meant by Individual codes? correct answers Each clinical statement of diagnosis must
have the correct code assignment. An individual patient may have many diagnoses (or
procedures). Consequently a coded record for an episode will have at least one or potentially
many individual codes.QUESTIONS
What is meant by totality of codes and why is this important? correct answers The concept of
totality of codes is complex. It means that all codes necessary to give an accurate clinical picture
of the patient's diagnosis, problems or other reasons for an episode encounter, must be assigned
in accordance with the rules, conventions and standards of the classification. This is important as
it is possible for a list of codes to describe an episode incorrectly in terms of clinical coding rules
and standards even though the individual codes selected are correct.
What is meant by sequencing of codes, why is this important and what is a significant aspect of
this? correct answers Codes must be sequenced in accordance with clinical coding standards to
provide consistent data for statistical analysis. A significant aspect of sequencing is the selection
of the main condition treated
How many steps make up the coding process? correct answers Four
What is step one of the four step coding process? correct answers Step One
Analyse medical terminology to determine lead term(s) and modifier(s)
What is step two of the four step coding process? correct answers Step Two
Locate the lead term(s) in the Alphabetical Index (ICD-10 Volume 3)
What is step three of the four step coding process? correct answers Step Three
Assign a tentative code(s) using the Alphabetical Index and taking into account all rules,
conventions and standards.
, What is step four of the four step coding process? correct answers Step Four
Verify the code(s) using the Tabular List (ICD-10 Volume 1) and taking into account
instructional notes.
If there is a doubt as to where a condition should be coded, what chapters must take priority?
correct answers The 'special group' chapters must take priority.
How many chapters make up ICD-10? correct answers 22 chapters
Name the types of chapters within ICD-10, describe briefly their content and give the chapter
numbers that fall within each type. correct answers Special group chapters
Chapters I-V, XV-XVII and XIX classify conditions that do not focus on any one body system.
In general, conditions are primarily classified to one of the 'special group' chapters.
Body system chapters
Chapters VI-XIV classify conditions according to the body system they affect.
Other chapters
Chapters XVIII and XX-XXII classify other disorders and factors which do not sit comfortably
in either a special group or body system chapter
What character levels must code assignment be made to, within ICD-10, to make the code valid?
correct answers Code assignment must always be made to four character level or five character
level (where available and in line with fifth character coding standards), for the code to be valid
Describe what must be done when a three character code does not have fourth character
subdivisions and why this is. correct answers Where a three character category code is not
subdivided into four character subdivisions the 'X' filler must be assigned in the fourth character
field so the codes are of a standard length for data processing and validation. The code is still
considered a three character code from a classification perspective.
Where a three character code requires assignment of both the 'X' filler and a fifth character
subdivision, the 'X' filler must continue to be recorded in the fourth field before the fifth
character.
Why are cross reference provided in the ICD index? correct answers Cross references are
provided in the Alphabetical Index to ensure that all possible terms or its synonyms are
referenced by the coder. Cross references explicitly direct the coder to other entries in the index
Name the two types of cross reference found within ICD-10 and describe their purpose. correct
answers See
This is an explicit direction to look elsewhere as no codes can be found alongside this cross
reference. It is used to direct the coder to another lead term in the Alphabetical Index where
complete information can be found. It is also used after anatomical sites to remind the coder that
the Alphabetical Index is organised by condition.
See also
This is a reminder to look under another lead term if the term the coder is looking for cannot be
found modified in any way under the first lead term.