Ch 5 - Coding 1-27

Front 1

the source document for coding and reporting diagnoses and procedures is

Back 1

the medical record

Front 2

the ______ ________ should be reviewed to determine the specific reason for the encounter and the conditions treated

Back 2

entire record

Front 3

Is it appropriate for a coder to assign a diagnosis based solely on a physicians orders for prescribed medications without the physicians documentation of the diagnosis being treated?

Back 3

no

Front 4

True/False: A coder can add a diagnosis without the approval of a physician

Back 4

false

Front 5

True/false: Many physicians are not aware of coding and reporting guidelines

Back 5

true

Front 6

What should a coder do if it appears that another diagnosis should be designated as the principal diagnosis, or if conditions not listed should be reported?

Back 6

follow the health care facility's guidelines for obtaining a corrected diagnostic statement

Front 7

Examples of reports that a physician may list principle diagnosis on:

Back 7

admission record (face sheet), progress notes, discharge summary

Front 8

Review of the inpatient medical record should begin with the

Back 8

discharge summary

Front 9

Discharge summary provides:

Back 9

a synopsis of pt's hospital stay including reason for admission, significant diagnostic findings, treatment given, pt's course in the hospital, follow up plan, final diagnostic statement

Front 10

If conditions mentioned elsewhere in the body but do not warrant reporting, ____________.

Back 10

the medical record should be reviewed further to determine whether such conditions meet the criteria for reportable diagnoses as defined the UHDDS

Front 11

_______ ________ do not always contain sufficient info for providing the required specificity in coding.

Back 11

recorded diagnoses

Front 12

If test findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment,

Back 12

ask the physician whether the diagnosis should be added

Front 13

True/False: it is appropriate to base code assignment on the documentation of other physicians involved in the care and treatment of pt as long as there is no conflicting info from the attending physician

Back 13

true

Front 14

code assignment is generally based on the

Back 14

attending physician's documentation

Front 15

If documentation from different physician's conflicts, then

Back 15

the attending physician should be queried for clarification because he is ultimately responsible for the final diagnosis

Front 16

when coding outpatient lab, pathology, and radiology encounters in hospital based as well as stand alone facilities,

Back 16

it is appropriate to assign codes on the basis of the written interpretation by a radiologist or pathologist

Front 17

True/false: it is appropriate to assign a procedure code based on documentation by the nonphysician professional who provided the service.

Back 17

true

Front 18

code assignment depends on the info available at the _____ of code assignement

Back 18

time

Front 19

conditions documented on previous encounters may not be ________ ________ for the current encounter.

Back 19

clinically relevant

Front 20

when reporting a recurring condition, and it is still valid for the outpatient encounter or inpatient admission,

Back 20

the recurring condition should be documented in the medical record with each encounter/admission

Front 21

PRV

Back 21

patient's reason for visit

Front 22

the PRV is reported on unscheduled outpatient visits to:

Back 22

identify the main reason the patient sought treatment

Front 23

How many diagnosis codes can be reported in the PRV field on the electronic claim?

Back 23

one

Front 24

if there are multiple conditions present in PRV,

Back 24

the code most likely to justify the patient encounter should be reported

Front 25

POA

Back 25

present on admission

Front 26

data element approved by the national uniform billing committee for inpatient reporting

Back 26

POA

Front 27

applies to the diagnosis codes for claims involving inpatient admissions to general acute care hospitals or other facilities

Back 27

POA