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A patient is seen in the office for the following conditions: chest pain, chronic hypertension, and controlled diabetes mellitus.  The provider orders a blood glucose level, chest xray, and EKG.  For medical necessity the chest xray would be linked to the _______
chest pain
A patient is seen in the hospital emergency dept for treatment of multiple lacerations.  The patient also complains of dizziness and a severe headache that is unrelieved by pain medications.  The emergency dept physician orders a brain scan and performs extensive suturing.  For medical necessity the suturing would be linked to the ________.
lacerations
The ICD-9-CM _____ arranges codes and descriptions in numerical order, and it contains 17 chapters that classify diseases and injuries, 2 supplemental classifications, and 4 appendices.
Tabular List of Diseases
The Glossary of Mental Disorders Appendix, previously found in ___________ of ICD-9-CM permanently removed from ICD-9-CM as of Oct 1 2004, because of its content can be found in the ___________ published by the APA.
Diagnostic and Statistical Manual of Mental Disorders (DSM)
The codes that are reported for patient encounters when a circumstace other than disease or injury is documented are called ________
V Codes
The supplementary classification located in the ICD-9-CM Tabular List of Diseases that describes external causes of injury poisoining, or other adverse reactions affecting a patient's health contain _____
E Codes
Appendix A of ICD-9-CM contains ________ which are reported to state cancer registries.
Morphology of Neoplasms - M codes
New growths or tumors in which cell reproduction is out of control are called _________
Neoplasms
Appendix C of ICD-9-CM which contains the American Hospital Formulary Services List number and its ICD-9-CM equivalent code number is titled ________
Classification of Drugs by AHFS List
Appendix D of ICD-9-CM contains the ______ which is based on employment injury stats adopted by the 10th Intl conference of Labor Stats
Classification of Industrial Accidents According to Agency
Appendix E of ICD-9-CM contains the ________ which are organized beneath section headings
List of Three Digit Categories
The alphabetical listing of ICD-9-CM main terms or conditions printed in boldfaced type that may be expressed as nouns adjectives, or eponyms is called the _______
Alphabetical Index to Diseases
The _____ contains adverse effects and poisonings associated with medicinal, chemical, and biological substances
Table of Drugs and Chemicals
Spaces between words and single hyphens between words are ignored when locating main terms in the ICD-9-CM indexes which means the ______ style of alphabetization is used
letter-by-letter
For the following list of main termsfound in the ICD9-CM Index to Diseases, main term Laythyrism-Launois' syndrome-Launois-Cleret syndrome is not in alphabetical order
Launois-Cleret syndrome
When numerical characters and words appear under a main term or subterm, they are listed in _____ order
numerical
Main terms are printed in ________ type and are followed by the code number
boldfaced
Qualifying words that are contained in parantheses after the main term which do not have to be included in the diagnostic description for the code number listed afte rthe parantheses to be assigned are called __________
nonessential modifiers
Subterms are considered ____________ and they qualify the main term by listing alternative sites, etiology, or clinical status
essential modifiers
The provider documents "acute athsmatic attack".  The main term in the Index to Diseases is __________
athsmatic
The provider documents "history of affctive psychosis".  The main term in the Index to Diseases is _________
History
Order the list of terms according to letter by letter alphabetization: Hb, Hayem-Faber syndrom, H disease, Hazard-Crile tumor, Hay, Health, Headache, Hgb, Head, Haygarth's nodosities.
Hay, Hayem-Faber syndrome, Haygarth's nodosities, Hazard-Crile tumor, Hb, H disease, Head, Headache, Health, Hgb,
The hospital version of commercial ICD-9-CM coding manuals includes the _________ as a combined alphabetical index and numerical listing of inpatient procedures and services
Tabular List of Procedures and Index to Procedures
Hospital outpatient departments and health care providers offices use the _________ which is published by the American Medical Association
Current Procedural Terminology CPT and Healthcare Common Procedure Coding System Level II HCPCS
HCPCS Level III local codes were eliminated ________ because they may have duplicated national codes, may have identified brand names rather than product catergories, and/or may have varied in use from locality to locality
December 31, 2003
The ICD-9-CM Index to Procedures and Tabular List of Procedures contain _________ sections
two
The ICD-9-CM Tabular List of Procedures contains ________ chapters
17
The guidelines for coding and reporting using ICD-9-CM have been approved by the four organizations that comprise the _________
cooperating parties for the ICD-9-CM
The abbreviations for the four organizations that develop and approve the coding guidelines are _________
AHA, AHIMA, CMS, NCHS
Adherence to the coding guidelines when assigning ICD-9-CM diagnosis and procedure codes is required by _________ legislation
HIPAA
The guidelines use the term _______ to indicate all health care settings including inpatient hospital admissions
encounter
The term ________ is used throughout the guidelines to refer to physicians or any qualified health care practitioners who are legally accountable for establishing the patient's diagnosis
provider
The ICD-9-CM uses an ____ format for ease of reference.
indented
Finish the sequence: Main Term, Subterm, ->
2nd qualifier, 3rd qualifier
These are diseases or syndromes that are named for people
Eponyms
The Index to Diseases and Index to Procedures contain ________ to save space
abbreviattions
NEC and NOS mean and are different because
Not elsewhere classifiable, and not otherwise specified; NEC can't be found in the index, and NOS was not provided by the record
These are used in the Index to Diseases to identify manifestation codes
Slanted Brackets
These are always reported as secondary codes
manifestation codes
These are used in the Tabular List of Diseases and Tabular List of Proecures to enclose synonyms, alternative wording, or explanatory phrases
Square Brackets
These are used in both the ICD-9-CM indexes and tabular lists to enclose nonessential modifiers
Parantheses
This is used after an incomplete term in the Tabular List of Diseases and Tabular List of Procedures when one or more additional terms included after it are to be included in teh diagnostic statement
Colon
Certain main terms in the Index to Diseases are followd by ______________ which define terms, provide coding instruction, and list fifth-digit classifications
Boxed Notes
The ICD-9-CM index to diseases contain ______ which organize subterms, 2nd qualifiers, and 3rd qualifiers and their codes in columns and rows to make it easier to select the proper code
Tables
Tables and locations:
Hypertension - embedded in Index to Diseases: Neoplasm - embedded in Index to Diseases: Table of Drugs and Chemicals - back of Index
This appears immediately below ICD-9-CM Tabular List of Diseases or Tabular List of Procedures codes to further define or provide examples
Includes Notes
This appears below a code to direct the coder to another location in the tabular list to classify conditions or procedures that are not part of the same code
Excludes Notes
These are listed below certain four and five digit ICD-9-CM codes in the Tabular List of Disease and the Tabular List of Procedures.  They include conditions or procedures for which that code number is to be assigned
Inclusion Terms
These are assigned because patient record documentation is insufficient to assign a more specific coe
Unspecified code
Wherever an etiology and manifestation combination of codes exist the Tabular List of Diseases will have code that contains these notes
use additional code for etiology and code first underlying disease for manifestation
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