CDIP Domain 1: Clinical Coding Practice Questions and Answers 100% Correct!

Coding Clinic - ANSWER-Valuable reference tool for coders that is published by AHA each quarter CPT - ANSWER-Current Procedural Terminology MS-DRGs - ANSWER-Medicare Severity-Diagnosis Related Groups CPT Assistant - ANSWER-Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - ANSWER-Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - ANSWER-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 - ANSWER-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 - ANSWER-Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - ANSWER-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 - ANSWER-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? - ANSWER-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 - ANSWER-Diagnosis that, after study, is the reason for the patient's admission to the hospital. Secondary diagnoses - ANSWER-Additional supporting information for the conditions the pat