HIM 324 EXAM 2
When would you code R99?
- when no cause of death is present
- "ill-defined and unknown cause if mortality"
Symptom
- any subjective evidence of disease reported by the patient
Sign
- an objective evidence of a disease observed by the physician
Abnormal Tumor Markers
- objective measurements of biochemical substances that are indicative of the presence of a
tumor
When would you code signs and symptoms?
- when there is no definitive diagnosis
- when the sign and symptoms are not associated with the diagnosis
Transient
- symptoms that will come and go
Glasgow Coma Scale (GCS)
- a method to describe the level of consciousness of patients with an acute brain injury that
could be the result of trauma
When should coma scale codes be coded?
,- they are sequenced after the diagnosis code
What does the 7th character in the coma scale indicate?
- it indicates when the scale was recorded
When should you code the total score of from the coma scale?
- when there are no other separate scores to the scale
What is not coded for inpatient?
- abnormal findings
When should a coder include abnormal findings for inpatient?
- when the physician states their clinical significance or to add specificity to a diagnosis
What 2 root operations might be performed for diagnostic studies?
- excision or drainage
Measuring and Monitoring Codes
- identify and describe procedures for determining the level of a physiological or physical
function
Measurement
- determining the level at a point in time
Monitoring
- determining the level over a period of time
For Z codes, what must be be coded if a procedure is performed?
, - a corresponding procedure code with the diagnosis Z code
Personal History Codes
- explains a past medical condition that no longer exists and is not receiving any treatment
but has the potential for recurrence and needs to be monitored
- these codes may be used in conjunction with follow-up codes
Family History Codes
- used when a patient has a family member(s) who has had a particular disease that causes
the patient to be at higher risk of also contracting the disease
- may be used in conjunction with screening codes to explain the need for a test or procedure
Status Codes
- indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past
disease or condition
- should not be used with a diagnosis code from the body system chapter
- example: the presence of a prosthesis or mechanical device resulting from past treatment
Encounters for observation and evaluation of newborn for suspected diseases
- these infants do not have signs or symptoms of the disease
Follow-Up Codes
- code means that the patient has been fully treated for the condition that no longer exists
Screening
- testing performed to detect disease in asymptomatic individuals so that early detection and
treatment can be provided
If a patient has some physical sign or symptom of the disease, would it be called a screening
test?
- no
When would you code R99?
- when no cause of death is present
- "ill-defined and unknown cause if mortality"
Symptom
- any subjective evidence of disease reported by the patient
Sign
- an objective evidence of a disease observed by the physician
Abnormal Tumor Markers
- objective measurements of biochemical substances that are indicative of the presence of a
tumor
When would you code signs and symptoms?
- when there is no definitive diagnosis
- when the sign and symptoms are not associated with the diagnosis
Transient
- symptoms that will come and go
Glasgow Coma Scale (GCS)
- a method to describe the level of consciousness of patients with an acute brain injury that
could be the result of trauma
When should coma scale codes be coded?
,- they are sequenced after the diagnosis code
What does the 7th character in the coma scale indicate?
- it indicates when the scale was recorded
When should you code the total score of from the coma scale?
- when there are no other separate scores to the scale
What is not coded for inpatient?
- abnormal findings
When should a coder include abnormal findings for inpatient?
- when the physician states their clinical significance or to add specificity to a diagnosis
What 2 root operations might be performed for diagnostic studies?
- excision or drainage
Measuring and Monitoring Codes
- identify and describe procedures for determining the level of a physiological or physical
function
Measurement
- determining the level at a point in time
Monitoring
- determining the level over a period of time
For Z codes, what must be be coded if a procedure is performed?
, - a corresponding procedure code with the diagnosis Z code
Personal History Codes
- explains a past medical condition that no longer exists and is not receiving any treatment
but has the potential for recurrence and needs to be monitored
- these codes may be used in conjunction with follow-up codes
Family History Codes
- used when a patient has a family member(s) who has had a particular disease that causes
the patient to be at higher risk of also contracting the disease
- may be used in conjunction with screening codes to explain the need for a test or procedure
Status Codes
- indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past
disease or condition
- should not be used with a diagnosis code from the body system chapter
- example: the presence of a prosthesis or mechanical device resulting from past treatment
Encounters for observation and evaluation of newborn for suspected diseases
- these infants do not have signs or symptoms of the disease
Follow-Up Codes
- code means that the patient has been fully treated for the condition that no longer exists
Screening
- testing performed to detect disease in asymptomatic individuals so that early detection and
treatment can be provided
If a patient has some physical sign or symptom of the disease, would it be called a screening
test?
- no
