D521-Introduction to Medical Coding
identification of a disease by a licensed
Diagnosis
provider
Refers to ill health in an individual and
Morbidity the levels of ill health in a population or
group.
Mortality the state of being subject to death
a secondary condition that is present on
Comorbidity admission and causes an increase in
length of stay (LOS)
a secondary condition that arises during
Complication hospitalization and causes an increase
in length of stay (LOS)
that condition established after study,
which is found to be primarily responsible
Principal diagnosis
for admission of the patient to the hospi-
tal
The first version of ICD used for both
What is a characteristic of ICD-6?
death classification and disease indexing
What was the first ICD revision for which The United States developed its own ver-
an alternate was made due to disagree- sion of ICD-8 based on disagreements
ments? over the circulatory section.
Which characteristic of ICD-10-PCS rep-
No diagnostic information is included.
resents a difference from ICD-9-CM?
a professional organization for health
American Health Information Manage-
information management (HIM) profes-
ment Association (AHIMA)
sionals
Non profit group or alliance of member
hospitals and health care organizations
American Hospital Association (AHA) that promote the interests of hospitals.
It is an advocacy group for health care
organizations, particularly hospitals
A group within the United Nations re-
World Health Organization (WHO) sponsible for human health, including
combating the spread of infectious dis-
, D521-Introduction to Medical Coding
eases and health issues related to nat-
ural disasters.
eight categories that constitute a chrono-
History of Present Illness (HPI)
logical description of an illness.
How long have you had the sore throat?
(duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become
better or worse? (timing)
How does it compare to other sore
throats you have had? (severity)
History of Present Illness (HPI) eight cat-
egories Do you also have other symptoms? (as-
sociated signs and symptoms)
What are you doing when it hurts? (con-
text)
How would you describe the pain? (qual-
ity)
What have you done to obtain relief? Did
it work? (modifying factors)
Illegible physician handwriting
Illogical physician diagnosis documenta-
tion
Common Diagnosis coding process er- Lack of physician documentation
rors
Transcription errors by typist or
voice-recognition systems
Content of the rest of the patient's med-
ical record does not support the diagno-
identification of a disease by a licensed
Diagnosis
provider
Refers to ill health in an individual and
Morbidity the levels of ill health in a population or
group.
Mortality the state of being subject to death
a secondary condition that is present on
Comorbidity admission and causes an increase in
length of stay (LOS)
a secondary condition that arises during
Complication hospitalization and causes an increase
in length of stay (LOS)
that condition established after study,
which is found to be primarily responsible
Principal diagnosis
for admission of the patient to the hospi-
tal
The first version of ICD used for both
What is a characteristic of ICD-6?
death classification and disease indexing
What was the first ICD revision for which The United States developed its own ver-
an alternate was made due to disagree- sion of ICD-8 based on disagreements
ments? over the circulatory section.
Which characteristic of ICD-10-PCS rep-
No diagnostic information is included.
resents a difference from ICD-9-CM?
a professional organization for health
American Health Information Manage-
information management (HIM) profes-
ment Association (AHIMA)
sionals
Non profit group or alliance of member
hospitals and health care organizations
American Hospital Association (AHA) that promote the interests of hospitals.
It is an advocacy group for health care
organizations, particularly hospitals
A group within the United Nations re-
World Health Organization (WHO) sponsible for human health, including
combating the spread of infectious dis-
, D521-Introduction to Medical Coding
eases and health issues related to nat-
ural disasters.
eight categories that constitute a chrono-
History of Present Illness (HPI)
logical description of an illness.
How long have you had the sore throat?
(duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become
better or worse? (timing)
How does it compare to other sore
throats you have had? (severity)
History of Present Illness (HPI) eight cat-
egories Do you also have other symptoms? (as-
sociated signs and symptoms)
What are you doing when it hurts? (con-
text)
How would you describe the pain? (qual-
ity)
What have you done to obtain relief? Did
it work? (modifying factors)
Illegible physician handwriting
Illogical physician diagnosis documenta-
tion
Common Diagnosis coding process er- Lack of physician documentation
rors
Transcription errors by typist or
voice-recognition systems
Content of the rest of the patient's med-
ical record does not support the diagno-
