CDIP Domain 1: Clinical Coding Practice, Questions & Answers, 100% Accurate.
Coding Clinic - -Valuable reference tool for coders that is published by AHA each quarter
CPT - -Current Procedural Terminology
MS-DRGs - -Medicare Severity-Diagnosis Related Groups
CPT Assistant - -Monthly p...
Coding Clinic - ✔✔-Valuable reference tool for coders that is published by AHA each quarter
CPT - ✔✔-Current Procedural Terminology
MS-DRGs - ✔✔-Medicare Severity-Diagnosis Related Groups
CPT Assistant - ✔✔-Monthly publication by the AMA that provides coding advice for CPT coding
scenarios
Encoder Nosology - ✔✔-Provides coding professionals from the encoder company that are available to
help answer tough coding questions
History & Physical - ✔✔-Provides the initial chief complaint and initial impressions of the provider when
the patient is first admitted. It also has a comprehensive physical review of the patient's body systems
and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to
treat the patient.
Progress Notes - ✔✔-Provide information about what is going on with the patient on a day-to-day basis;
they should include the diagnoses that are being treated as well as any information about any changes
in the patient's well-being and tests/procedures being performed.
Operative and Pathology Reports - ✔✔-Summarize the invasive procedures performed and any samples
that are removed from the patient's body
Pathology report - ✔✔-Provides detailed information from the pathologist of the facility as to the status
of the tissues or organs removed from the patient's body
, Encoder - ✔✔-Specialty software used to facilitate the assignment of diagnostic and procedural codes
according to the rules of the coding system
What is the value of utilizing coding software? - ✔✔-It facilitates accurate coding by providing links to
coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with
additional information for the coder to consider when placing codes into the encoder
Principal diagnosis - ✔✔-Diagnosis that, after study, is the reason for the patient's admission to the
hospital.
Secondary diagnoses - ✔✔-Additional supporting information for the conditions the patient is being
cared for
MCC - ✔✔-Major Complication or Comorbidity
CC - ✔✔-Complication or Comorbidity
CMI - ✔✔-Case Mix Index
LOS - ✔✔-Length of Stay
Complication - ✔✔-A condition arising during the hospital stay that prolongs the LOS by at least one day
in approximately 75% of the cases
Comorbidity - ✔✔-A pre-existing condition which because of its presence with the principal diagnosis
will increase the LOS by at least one day in 75% of the cases
Primary procedures - ✔✔-Procedure codes that best represent the procedure that has been performed
Secondary procedures - ✔✔-Do not typically impact the MS-DRG; however, they are important for
capturing the details of the care the patient has received while in the hospital.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller QuickPass. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.49. You're not tied to anything after your purchase.
