Question 1

What is the main term in "aspiration pneumonia"?

Accepted Answer

The answer of What is the main term in "aspiration...

Question 2

What is the subterm in "esophageal reflux"?

Accepted Answer

The answer of What is the subterm in "esophageal reflux"?...

Question 3

What is the main term in "esophageal reflux"?

Accepted Answer

The answer of What is the main term in "esophageal...

Question 4

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Accepted Answer

A) True 
 B)False

Question 5

MATCHING
Match the following with the correct term or definition.
-Modifiers of the main term that have an effect on the appropriate code choice

Accepted Answer

A)  Tabular List
B)  See also
C)  Subterms
D)  Discharge summary
E)  Coding ClinicF) ERG) Differential diagnosisH) Chief complaintI) The first basic step in coding the principal diagnosisJ) Nonessential modifiersK) D) and F)
L) A) and D)

Question 6

When evaluating an ER record,a coder should look for the ____.

Accepted Answer

A)  diagnosis
B)  chief complaint
C)  probable diagnosis
D)  differential diagnosisE) B) and C)
F) A) and D)

Question 7

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Accepted Answer

A) True 
 B)False

Question 8

The main term is ____.

Accepted Answer

A)  always identified in italics
B)  a review of the patient's hospital course
C)  a term identifying disease conditions or injuries
D)  a word found in parentheses that enclose explanatory information that does NOT affect the codeE) B) and D)
F) B) and C)

Question 9

What is the main term in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the main term in "rheumatoid...

Question 10

What is the subterm in "infantile eczema"?

Accepted Answer

The answer of What is the subterm in "infantile eczema"?...

Question 11

The main term in "aplastic anemia" is ____.

Accepted Answer

A)  anemia
B)  aplasia
C)  aplastic
D)  none of the aboveE) All of the above
F) A) and B)

Question 12

MATCHING
Match the following with the correct term or definition.
-Emergency Room

Accepted Answer

A)  Tabular List
B)  See also
C)  Subterms
D)  Discharge summary
E)  Coding ClinicF) ERG) Differential diagnosisH) Chief complaintI) The first basic step in coding the principal diagnosisJ) Nonessential modifiersK) E) and J)
L) A) and G)

Question 13

The first step in coding the principal diagnosis is to ____.

Accepted Answer

A)  identify the diagnosis and the principal procedure
B)  identify main term(s) in the Alphabetic Index
C)  review the medical record
D)  review any subterms under the main term in the IndexE) A) and B)
F) A) and C)

Question 14

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

Accepted Answer

A) True 
 B)False  True

Question 15

What is the subterm in "rheumatoid arthritis"?

Accepted Answer

The answer of What is the subterm in "rheumatoid arthritis"?...

Question 16

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?

Accepted Answer

A)  Coders may not have a discharge summary at the time of coding.
B)  If the patient is in the hospital for a long stay,the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay.
C)  Physicians list diagnoses that are not currently being treated and are only in the patient's history.
D)  All of the options are correct.E) B) and D)
F) A) and B) D

Question 17

What is the subterm in "aspiration pneumonia"?

Accepted Answer

Aspiration

Question 18

What is the main term in "calculus of the ureter"?

Accepted Answer

The answer of What is the main term in "calculus...

Question 19

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

Accepted Answer

A) True 
 B)False

Question 20

MATCHING
Match the following with the correct term or definition.
-When a patient displays a symptom that could represent a variety of diagnoses

Accepted Answer

A)  Tabular List
B)  See also
C)  Subterms
D)  Discharge summary
E)  Coding ClinicF) ERG) Differential diagnosisH) Chief complaintI) The first basic step in coding the principal diagnosisJ) Nonessential modifiersK) G) and H)
L) G) and J)

Exam 4: Basic Steps of Coding

What is the main term in "aspiration pneumonia"?

Correct AnswerverifiedShow Answer

What is the subterm in "esophageal reflux"?

Correct AnswerverifiedShow Answer

What is the main term in "esophageal reflux"?

Correct AnswerverifiedShow Answer

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Correct AnswerverifiedShow Answer

MATCHING Match the following with the correct term or definition. -Modifiers of the main term that have an effect on the appropriate code choice

Correct AnswerverifiedShow Answer

When evaluating an ER record,a coder should look for the ____.

Correct AnswerverifiedShow Answer

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Correct AnswerverifiedShow Answer

The main term is ____.

Correct AnswerverifiedShow Answer

What is the main term in "rheumatoid arthritis"?

Correct AnswerverifiedShow Answer

What is the subterm in "infantile eczema"?

Correct AnswerverifiedShow Answer

The main term in "aplastic anemia" is ____.

Correct AnswerverifiedShow Answer

MATCHING Match the following with the correct term or definition. -Emergency Room

Correct AnswerverifiedShow Answer

The first step in coding the principal diagnosis is to ____.

Correct AnswerverifiedShow Answer

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

Correct AnswerverifiedTrue

What is the subterm in "rheumatoid arthritis"?

Correct AnswerverifiedShow Answer

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?

Correct AnswerverifiedD

What is the subterm in "aspiration pneumonia"?

Correct AnswerverifiedAspiration

What is the main term in "calculus of the ureter"?

Correct AnswerverifiedShow Answer

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

Correct AnswerverifiedShow Answer

MATCHING Match the following with the correct term or definition. -When a patient displays a symptom that could represent a variety of diagnoses

Correct AnswerverifiedShow Answer

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True

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D

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Aspiration

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