Certified Coding Specialist - Questions With Precise
Solutions
Both steroid induced diabetes and diabetes due to use of steroids are
considered ___________ diagnoses Correct Answer - secondary
SIRS criteria- 2 or more Correct Answer - Temp > 100.4 or <96.8, HR
>90BPM, Resp- >20 or PaCO2 <32 mm Hg, WBC >12,000 or <4,000
Septicemia Correct Answer - systemic disease associated with the
presence of pathological microorganisms/ toxins in the blood
SIRS- systemic inflammatory response system Correct Answer -
systemic response to the infection or trauma/burns or cancer
Sepsis Correct Answer - SIRS due to infection
Query Correct Answer - Question posed to a provider to obtain
additional clarifying documentation to improve the specificity and
completeness of the data used to assign diagnosis and procedure codes in the
patients health record
Multiple choice query Correct Answer - -Includes clincially
significant/reasonable options
-There may be only one reasonable options
-Include additional options such as 'clinically undetermined' and 'other' to
allow for free text.
Yes/ No format query Correct Answer - Should be constructed to
include the additional options associated with multiple choice queries. EX-
'other, 'clinically undetermined', 'not clinically significant and integral to'
New diagnoses cannot be derived from a _____________ Query Correct
Answer - yes/no
, Verbal queries are documented ___ _______ of discussion or __________ following
Correct Answer - at time, immediately
UHDDS Correct Answer - Uniform Hospital Discharge Data Set
uniform hospital discharged data set is used by Correct Answer -
hospitals to report inpatient data elements in standardized manner
Principal diagnosis is that condition established _____ study to be chiefly
responsible for occasioning the admission of the pt to the hospital Correct
Answer - after
uhdds has expanded to include all _____ _________ settings Correct Answer -
non outpatient
The condition established after study to be chiefly responsible for occasioning
the admission of the pt to the hospital is Correct Answer - Principal
diagnosis
The definition of a ____ ______ is one that is performed for definitive tx rather
than for diagnostic or exploratory purposes or when it is necessary to take
care of a complication Correct Answer - Principal procedure
Diagnoses that relate to an earlier episode which have no bearing on the
current hospital stay are to be _________. Correct Answer - excluded
If two procedures appear to be principal the one most related to the ________
__________ should be selected as the principal procedure Correct Answer -
principal diagnosis
Any and all significant procedures should still be reported, defined as
Correct Answer - -Surgical in nature
-Carries procedural risk
-Carries anesthetic risk
Requires specialized training
Discharge Disposition is a ____ ______ code Correct Answer - two digit
Solutions
Both steroid induced diabetes and diabetes due to use of steroids are
considered ___________ diagnoses Correct Answer - secondary
SIRS criteria- 2 or more Correct Answer - Temp > 100.4 or <96.8, HR
>90BPM, Resp- >20 or PaCO2 <32 mm Hg, WBC >12,000 or <4,000
Septicemia Correct Answer - systemic disease associated with the
presence of pathological microorganisms/ toxins in the blood
SIRS- systemic inflammatory response system Correct Answer -
systemic response to the infection or trauma/burns or cancer
Sepsis Correct Answer - SIRS due to infection
Query Correct Answer - Question posed to a provider to obtain
additional clarifying documentation to improve the specificity and
completeness of the data used to assign diagnosis and procedure codes in the
patients health record
Multiple choice query Correct Answer - -Includes clincially
significant/reasonable options
-There may be only one reasonable options
-Include additional options such as 'clinically undetermined' and 'other' to
allow for free text.
Yes/ No format query Correct Answer - Should be constructed to
include the additional options associated with multiple choice queries. EX-
'other, 'clinically undetermined', 'not clinically significant and integral to'
New diagnoses cannot be derived from a _____________ Query Correct
Answer - yes/no
, Verbal queries are documented ___ _______ of discussion or __________ following
Correct Answer - at time, immediately
UHDDS Correct Answer - Uniform Hospital Discharge Data Set
uniform hospital discharged data set is used by Correct Answer -
hospitals to report inpatient data elements in standardized manner
Principal diagnosis is that condition established _____ study to be chiefly
responsible for occasioning the admission of the pt to the hospital Correct
Answer - after
uhdds has expanded to include all _____ _________ settings Correct Answer -
non outpatient
The condition established after study to be chiefly responsible for occasioning
the admission of the pt to the hospital is Correct Answer - Principal
diagnosis
The definition of a ____ ______ is one that is performed for definitive tx rather
than for diagnostic or exploratory purposes or when it is necessary to take
care of a complication Correct Answer - Principal procedure
Diagnoses that relate to an earlier episode which have no bearing on the
current hospital stay are to be _________. Correct Answer - excluded
If two procedures appear to be principal the one most related to the ________
__________ should be selected as the principal procedure Correct Answer -
principal diagnosis
Any and all significant procedures should still be reported, defined as
Correct Answer - -Surgical in nature
-Carries procedural risk
-Carries anesthetic risk
Requires specialized training
Discharge Disposition is a ____ ______ code Correct Answer - two digit
