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D521-Introduction to Medical Coding Practice questions for this set Terms in this set (59) Diagnosis identification of a disease by a licensed provider Morbidity Refers to ill health in an individual and the levels of ill health in a population o€8,10
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D521-Introduction to Medical Coding Practice questions for this set Terms in this set (59) Diagnosis identification of a disease by a licensed provider Morbidity Refers to ill health in an individual and the levels of ill health in a population o
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D521-Introduction to Medical Coding
Practice questions for this set
Terms in this set (59)
Diagnosis identification of a disease by a licensed provider
Morbidity Refers to ill health in an individual and the levels of ill health in a population or group.
Mortality the state of be...
Practice questions for this set
Terms in this set (59)
Diagnosis identification of a disease by a licensed provider
Morbidity Refers to ill health in an individual and the levels of ill health in a population or group.
Mortality the state of being subject to death
a secondary condition that is present on admission and causes an increase in length of
Comorbidity
stay (LOS)
a secondary condition that arises during hospitalization and causes an increase in
Complication
length of stay (LOS)
D521-Introduction to Medical Coding
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that condition established after study, which is found to be primarily responsible for
Principal diagnosis
admission of the patient to the hospital
What is a characteristic of ICD-6? The first version of ICD used for both death classification and disease indexing
What was the first ICD revision for which an The United States developed its own version of ICD-8 based on disagreements over
alternate was made due to disagreements? the circulatory section.
Which characteristic of ICD-10-PCS No diagnostic information is included.
represents a difference from ICD-9-CM?
American Health Information Management a professional organization for health information management (HIM) professionals
Association (AHIMA)
Non profit group or alliance of member hospitals and health care organizations that
American Hospital Association (AHA) promote the interests of hospitals. It is an advocacy group for health care
organizations, particularly hospitals
A group within the United Nations responsible for human health, including combating
World Health Organization (WHO)
the spread of infectious diseases and health issues related to natural disasters.
History of Present Illness (HPI) eight categories that constitute a chronological description of an illness.
How long have you had the sore throat? (duration)
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)
History of Present Illness (HPI) eight
categories
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? (modifying factors)
Illegible physician handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Common Diagnosis coding process errors
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
A combination of paper and electronic records; a health record that includes both
Hybrid Record
paper and electronic elements
A system of health record organization in which all the paper forms are arranged in
Integrated health record
strict chronological order and mixed with forms created by different departments
an independent organization that accredits healthcare organizations in the United
The Joint Commission
States based on performance standards
a single complete health record that combines data from a variety of sources within a
Longitudinal health record
D521-Introduction to Medical Coding
healthcare system
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