CDIP Domain 1: Clinical Coding Practice |62 questions with correct answers

Coding Clinic CORRECT ANSWER Valuable reference tool for coders that is published by AHA each quarter CPT CORRECT ANSWER Current Procedural Terminology MS-DRGs CORRECT ANSWER Medicare Severity-Diagnosis Related Groups CPT Assistant CORRECT ANSWER Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology CORRECT ANSWER Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical CORRECT 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 CORRECT 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 CORRECT ANSWER Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report CORRECT ANSWER Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed