ME2611 Learning Plan 3 Diagnostic Coding Study Worksheet Name: Part I Getting to Know [CD-10 CM Coding (1 point each-4 points total) Fill in the blank 1. refers to the “cause “of disease? 2. What is the first 3 digits in a diagnosis code called? 3. The abbreviation used in the tabular index NOS stands for 4. Which codes are used for the table of drugs and chemicals? Part II Abstracting the Diagnostic Statement (1 point each, 6 points total) Fill in the blank 1. Information pertinent to code selection is pulled from a variety of medical documents. Which document does M contain diagnosis information? (Patient Registration form, Progress Note, Operative Report) 2. The is the provider’s health history evaluation and physical assessment of the patient. 3. The is the statement in the patient’s own words that describes why the person is seeking medical attention. 4. The Operative Report is used for extracting and diagnostic information for patient who underwent surgery. 5. A is a disease that manifest over a long period because medical treatment has not resolved/cured it. 6. Coders who have questions on complicated cases can refer to the coding clinic which is a journal published by the Part III Steps of Diagnositc Coding (1 point each, 8 points) List (8) steps requiredfar accurate diagnostic Code assignment: 9°TJ9’E":’>P’.N.
1. Etiology: Refers to the “cause” of disease.
2. Three-digit Code: The first three digits in a diagnosis code.
3. NOS Abbreviation: The abbreviation used in the tabular index NOS stands for “Not Otherwise Specified.”
4. Drug and Chemical Codes: These codes are used for the table of drugs and chemicals.
1. Information pertinent to code selection is pulled from a variety of medical documents. The document that contains diagnosis information is the **Progress Note**.
2. The Health History Evaluation is the provider’s assessment of the patient’s health history and physical evaluation.
3. The Chief Complaint is the statement in the patient’s own words that describes why the person is seeking medical attention.
4. The Operative Report is used for extracting diagnostic information for patients who underwent surgery.
5. Chronic Condition: A chronic condition is a disease that manifests over a long period because medical treatment has not resolved/cured it.
6. Coders who have questions on complicated cases can refer to the **Coding Clinic**, which is a journal published by the American Hospital Association (AHA).
Patient Assessment: Review medical documents, including progress notes and test results.
Identify Diagnosis: Recognize the primary diagnosis or condition to be coded.
Locate in Index: Search the Alphabetic Index using the primary diagnosis term.
Verify Code: Check the code selection against the Tabular List for accuracy.
Additional Codes: Include additional codes for relevant coexisting conditions.
Code Modifiers: Apply any necessary code modifiers to specify details of the condition.
Documentation Review: Ensure documentation supports assigned codes for accurate reporting.
Coding Clinic Reference: Refer to the AHA’s Coding Clinic** for complex or ambiguous cases.
In summary, accurate diagnostic coding is a crucial component of healthcare record-keeping and billing. Understanding the basics of coding, abstracting diagnostic information, and following a systematic approach ensures that accurate and relevant information is communicated across healthcare systems, promoting effective patient care and management.
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