Final

Question 1

What is the proper way to interpret the NEC and NOS abbreviations?

a. Not elsewhere classified “in the medical record” and Not otherwise specified “in the code book”
b. Not elsewhere classified “in the code nook” and Not otherwise specified “in the medical record”

Answer 1

Not elsewhere classified “in the code nook” and Not otherwise specified “in the medical record”

Question 2

Indicates that a diagnosis is still possible - coded like it exists

Answer 2

Rule out

Question 3

Indicates that a diagnosis once considered likely is no longer possible - never coded

Answer 3

Ruled out

Question 4

Which type of excludes notes means NOT CODED HERE. Should never be used at the same time as the code above

a. Excludes 1
b. Excludes 2

Answer 4

Excludes 1

Question 5

Probable and possible should be coded as if the condition _______.

Exceptions to these are HIV and Influenza

Answer 5

Existed

Question 6

_____ means there is no seperate code for the condition in the alphabetic index even though the diagnostic statement is very specific

Answer 6

NEC

Question 7

_____ codes are used only when the diagnostic statement does not provide information to permit classificationto more specific code

Answer 7

NOS

Question 8

TRUE/FALSE: Coding unconfimed diagnoses as if established (such as probable, possible diagnosis) only applies to inpatient coding. This rule does not apply to outpatient coding.

Answer 8

True

Question 9

Site mentioned is secondary (Metastatic carcinoma to the lung)

Answer 9

Metastatic to

Question 10

site mentioned is primary (Metastatic carcinoma from the lung)

Answer 10

Metastatic from

Question 11

Most severe _____ is sequenced as principal (first) diagnosis

Answer 11

injury

Question 12

a complication such as an infection or inflammatory reaction due to the presence of a device, implant or graft that is functioning properly; use additional codes to identify the infection/inflammation

Answer 12

Nonmechanical

Question 13

a complication that results from a failure of a device, implant or graft – breakdown, displacement, leakage

Answer 13

Mechanical

Question 14

What type of excludes means not NOT INCLUDED HERE. Not part of the condition represented by the code.

a. Excludes 1
b. Excludes 2

Answer 14

Excludes 2

Question 15

________ codes are not used if injury or illness or any other signs or symtom related to the suspected condition is present.

Answer 15

Observation

Question 16

____ and ____ can be assigned only has the principal diagnosis or reason for encounter(observation). Never used has secondary

Answer 16

Z03, 204

Question 17

Focused on management of pain and symptoms, rather than aggressive treatment of disease; Used only as a secondary code; underlying disease is sequenced first

Answer 17

Palliative care

Question 18

If the late effect is due to injury, poisoning and certain other consequences of external causes (S00 – T88), a 7th character value for “_______” or “__” should be assigned

Answer 18

sequelae

Question 19

________ occurs when there is no exertion that has been expended. Pain is more severe and not easily controlled by nitoroglycerin

Answer 19

Unstable angina

Question 20

______ is less severe and is controlled. It is easily controlled by nitroglycerin

Answer 20

Angina pectoris