HIM CODING THEORY TEST

A Diagnosis Type 6 is assigned to:

A set of standardized terms and their synonyms that record patient findings, circumstances, events and interventions

SNOMED CT concepts are organized into ____ hierarchies.

Which is not apart of the SNOMED CT hierarchies

Hierarchies have multiple____which allows information to be expressed with different levels of detail and precision which means data can be entered or retrieved depending on the need.

A ______________ is a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.

Is a classification that allows for the categorizing of patient reason for encounter designed to be used in a primary care setting

Is a multi-axial classification of categories used to collect psychiatric disorders and underlying conditions

Includes gender, data of birth, and postal codes

Includes those interventions that are through a needle or catheter

Describes a situation in which the intervention is terminated before an expected outcome is achieved

Interventions from this section are solely used for obstetrics and neonates

This contains two characters and refers to "what is being done"

This coded to reflect the existence of a separate surgical wound which usually requires its own post-surgical care (example would be a free flap)

These are used to indicate quantitative measures related to the intervention

This instruction is provided to also code associated factors in a condition such as infecting organism, underlying causes, asterisk code, to further describe a person's condition

This consists of numeric listing in code number order and is organized by chapter, blocks, and categories

This represents a level of grouping between chapters and categories, an example would be: N60-N64

This can be at the fourth or fifth character of code and is used for "other" conditions (not specified)

Lead Term is located in the _____________________ binocular, using the name of the disease, injury or pathological condition

These conditions provide further information about conditions which are no longer present but are the cause of the current problem, often listed as "old, late effect, or due to previous"

Uses the code Z21 when there is no documentation of an indicator disease from the National Surveillance case definition list.

This is known as a drug resistant bacteria

This can only be coded when documented by a physician and not on the basis of laboratory values alone

Must be used as a type 3 to identify patients who have been exposed to or had contact with AIDS/HIV

This term describes when the microbiology report may indicate the patient has MRSA, VRE on their body but the patient is not sick with the illness, these are coded to "carriers

Is used by physicians to describe a patient who presents with a fever, and the cause is not determined after investigations are completed

This code must be assigned as a diagnosis type 1 or type 2 to describe organ failure as a result of severe sepsis

This describes when the healing process of a bone has not occurred and there is still separation of the bony structures involved in the fracture

This is often referred to as a THR where the femoral head and neck are replaced

This term is often referred to as herniation and/or protrusion of the intervertebral disc, and the condition may also be described as prolapsed disc or sequestrated disc.

This code is assigned as a MP when a patient returns to day surgery after the fracture has healed for removal of an internal fixation device such as a wire, pins or plate.

This describes a procedure which uses organ or tissue from an animal source

This condition can result from an adverse effect of medication taken internally as directed and is assigned the code L27^

This condition can be described as either spontaneous or compression when involving the vertebrae, it occurs in bones weakened by pre-existing disease such as osteoporosis, Paget's disease and neoplasia

A patient arrived in hospital for an elective hip arthroplasty for osteoarthritis. Surgery was performed using a dual component THR without incident. On the third day the patient developed a wound infection resulting from the device inserted. Staphylococci were found on the cultures. The patient required to stay in hospital for another 3 days until the infection has cleared. What would be the MRDX?

A 17 year old male patient arrived in the emergency room with pain in his knee after falling down a hill yesterday while skiing at Blue Mountain. The patient had an x-ray of the knee indicated there was a ligament injury of the right knee. The patient was transferred to an inpatient bed and kept overnight awaiting surgery in the morning. What would be the main problem for the emergency visit?

A female patient has developed cellulitis on her hand from an infected open wound which was caused by a cut from a garbage can. She is being treated with IV antibiotics for three days, and was discharged home. Which of the following would be the most responsible diagnosis?

An 77 year old male patient is admitted to treat degenerative arthritis of the right hip. On the history note it states the patient has diabetes type 2, hypertension and congestive heart failure. The patient was taken to the OR room where a THR was performed with excellent results. What would be the most responsible diagnosis?

A patient was admitted to hospital for a breast lumpectomy for infiltrating duct carcinoma. During the procedure the surgeon also removed all the axillary lymph nodes because of metastases. Post-op the patient had a chest tube inserted for pneumothorax. A CT scan of the chest performed before the patient was discharged indicated the pneumothorax had resided. What procedure would be sequenced first, also known as the principle procedure?

It is mandatory to assign the code Z51.1 and a CCI code for the administration of the pharmaceutical agent, plus a code from C00-C97 when a patient arrives in a hospital for the admission of:

This is a complication/side effect of cancer treatment, and can be a type 2 if it occurred during a patient's admission for initial treatment for cancer/or satisfies the criteria for a post-admit comorbidity

This is used as 5th digit for malignant secondary neoplasm

This information is necessary to capture if patients are requesting prophylactic surgery and is assigned the code Z80.-

This term is used when the patient is described as having cancer that has spread to multiple secondary sites

When a patient is admitted for this type of treatment, a code for the malignant disease is assigned as the MRDX/MP

An example of an intervention performed by an endoscopic approach would be:

A classification of categories used to collect psychiatric disorders and underlying conditions.

A doctor has documented on the face sheet of an emergency record a condition of a fracture of the right femur due to a fall from a ladder. After examination of the record the x-ray results indicate a fracture of the proximal end of the femur. What should be coded as the MP based on the rule for specificity?

When coding sequelae of injuries the following rule applies:

A 54 year old patient arrives in the emergency department complaining of coughing up blood. The emergency physician ordered a chest x-ray and a TB test. Results are pending at this time. An appointment was made for the patient to see a respirologist for the results of the test. The final diagnosis documented by the physician is hemoptysis and questionable TB of the lung. What would be could as the main problem?

A 38 year old female arrived in the emergency department with a laceration on her hand after falling from her patio. She has a past medical history of type 2 diabetes. The emergency physician sutured and dressing her wound under local anesthesia. The patient indicated she was feeling faint and a blood glucose tolerance test was performed indicating levels were higher than normal. The emergency physcian ordered her to be admitted to an inpatient bed for observation overnight to control her condition of diabetes. What would be the principal procedure for the ER visit?

A patient was admitted to hospital from the ER with a diagnosis of severe cough and the condition of impeding pneumonia. On the x-ray report done in the ER indicated the patient has severe bronchitis. The patient was given large doses of antibiotics. After 4 days in hospital the pneumonia was ruled out and the patient was discharged. The physician documents on the face sheet acute bronchitis. What code should the coder assign and the MRDX?

Is the building blocks of information, the raw facts and figures ( the elements, S01.90, V43.5, 1.YB.80.LA, 1811, F, age 47, outcome of visit - discharged home (D) or died (E)) - facts on their own have no meaning

Which of the following does not affect Data Quality?

Which of the following is NOT an axis of Systematized Nomenclature of Pathology (SNOP)?

Understanding the fundamental principles embodied within the knowledge, utilizing knowledge to make sense and have an insight of what is happening

A right breast neoplasm in the anatomical site of 5:00 would be given the code of _________