D521-Introduction to Medical Coding
1. Diagnosis identification of a disease by a licensed provider
2. Morbidity Refers to ill health in an individual and the levels of ill
health in a population or group.
3. Mortality the state of being subject to death
4. Comorbidity a secondary condition that is present on admission and
causes an increase in length of stay (LOS)
5. Complication a secondary condition that arises during hospitalization
and causes an increase in length of stay (LOS)
6. Principal diagno- that condition established after study, which is found to be
sis primarily responsible for admission of the patient to the
hospital
7. What is a charac- The first version of ICD used for both death classification
teristic of ICD-6? and disease indexing
8. What was the The United States developed its own version of ICD-8
first ICD revi- based on disagreements over the circulatory section.
sion for which
an alternate was
made due to dis-
agreements?
9. Which char- No diagnostic information is included.
acteristic of
ICD-10-PCS rep-
resents a dif-
ference from
ICD-9-CM?
10. American Health a professional organization for health information man-
Information Man- agement (HIM) professionals
agement Associ-
ation (AHIMA)
11.
, D521-Introduction to Medical Coding
American Hospi- Non profit group or alliance of member hospitals and
tal Association health care organizations that promote the interests of
(AHA) hospitals. It is an advocacy group for health care organi-
zations, particularly hospitals
12. World Health A group within the United Nations responsible for human
Organization health, including combating the spread of infectious dis-
(WHO) eases and health issues related to natural disasters.
13. History of Pre- eight categories that constitute a chronological descrip-
sent Illness (HPI) tion of an illness.
14. History of Pre- How long have you had the sore throat? (duration)
sent Illness (HPI)
eight categories 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? (modi-
fying factors)
15. Common Diag- Illegible physician handwriting
nosis coding
process errors Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
1. Diagnosis identification of a disease by a licensed provider
2. Morbidity Refers to ill health in an individual and the levels of ill
health in a population or group.
3. Mortality the state of being subject to death
4. Comorbidity a secondary condition that is present on admission and
causes an increase in length of stay (LOS)
5. Complication a secondary condition that arises during hospitalization
and causes an increase in length of stay (LOS)
6. Principal diagno- that condition established after study, which is found to be
sis primarily responsible for admission of the patient to the
hospital
7. What is a charac- The first version of ICD used for both death classification
teristic of ICD-6? and disease indexing
8. What was the The United States developed its own version of ICD-8
first ICD revi- based on disagreements over the circulatory section.
sion for which
an alternate was
made due to dis-
agreements?
9. Which char- No diagnostic information is included.
acteristic of
ICD-10-PCS rep-
resents a dif-
ference from
ICD-9-CM?
10. American Health a professional organization for health information man-
Information Man- agement (HIM) professionals
agement Associ-
ation (AHIMA)
11.
, D521-Introduction to Medical Coding
American Hospi- Non profit group or alliance of member hospitals and
tal Association health care organizations that promote the interests of
(AHA) hospitals. It is an advocacy group for health care organi-
zations, particularly hospitals
12. World Health A group within the United Nations responsible for human
Organization health, including combating the spread of infectious dis-
(WHO) eases and health issues related to natural disasters.
13. History of Pre- eight categories that constitute a chronological descrip-
sent Illness (HPI) tion of an illness.
14. History of Pre- How long have you had the sore throat? (duration)
sent Illness (HPI)
eight categories 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? (modi-
fying factors)
15. Common Diag- Illegible physician handwriting
nosis coding
process errors Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
