Ost 248 - Study guides, Class notes & Summaries

What document would be the best place to find information about the reason a patient presented for treatment and pertinent medical history? -Discharge summary -History and physical -Consultation report -Operative report - History and physical Which of the following does not impact the content or format of health record documentation? -Paper records -Electronic health records -Type of healthcare setting -Demographic information - Demographic information What document would be the best...

Which of the following would NOT be considered integral to the diagnosis of pneumonia? - Positive blood culture MM sl dry - Mucous membranes slightly dry TPN - : Total parenteral nutrition OSA - Obstructive sleep apnea FTVD - Full-term vaginal delivery LLQ - Left lower quadrant CTA - Clear to auscultation NSR - Normal sinus rhythm Which of these is NOT a purpose of the health record? - Reimbursement DOE - Dyspnea on exertion A hybrid health record is - A record that combines electroni...

Why must coders read all associated code descriptions in the Tabular list? - To match details in the physician documentation. To be in compliance with rules and guidelines. What would you find in the front of your code book that defines the rules and directions for accurate coding? - official guidelines The code that reports the most important reason for the patient's encounter is called the __________. - Principal diagnosis For what type of diagnosis must you code signs and symptoms in a...

Mr. Smith was admitted to Sunny Valley Rest Home with a pressure ulcer of the sacral region with full thickness skin loss with damage of the subcutaneous tissue extending to the underlying fascia. This would be reported with code(s) _____. - L89.153 Sally is seen in the office today because of a red, swollen area on her left side. After examination it is determined that she has a sebaceous cyst. This encounter should be reported with code(s) _____. - L72.3 chronic bullous disease of childh...

An inflammation of the esophagus due to acid reflux is known as - esophagitis The final diagnoses on a discharge summary reads "acute and chronic respiratory failure." The correct code(s) is (are) _____. - J96.20 angina pectoris with essential hypertension - I20.9 and I10 acute rheumatic endocarditis - I01.1 rheumatic aortic and mitral valve insufficiency - I08.0 rheumatic chorea with heart involvement - I02.0 rheumatic tricuspid stenosis - I07.0 mitral valve insufficiency and stenosis...

In the coding of secondary diagnoses, if the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, that diagnosis should ordinarily be coded. - True If the diagnosis documented at the time of discharge is qualified with such terms as "probable," "suspected," "likely," "questionable," "possible," "still to be ruled out," or other phrases indicating uncertainty, code the condition as if it existed or is established. -...

Coding professionals use the physicians _________ or _________ to assign ICD-10-CM codes describing why the patient was seen - As a coding specialist, it is your job to translate this explanation and to a diagnosis code so that everyone involved will clearly understand the issues of a particular patient and a particular time The purpose of using health care coding languages is to enable the ________ of information, in a specific and efficient way, between all those involved in health care. ...

Written report explaining the background and current issues used to make the decision to admit the patient into the hospital - History and Physical (H&P) The ________ list pharmaceuticals and ________ that may cause poisoning or _______ and the human body - Table of drugs and chemicals; chemicals; adverse effects The diagnosis codes that you report explained the justification for the procedure, service, or treatment provided to a patient during his or her and counter - Medical necessity Re...

OST 248 Test 1 Practice Questions and Answers (100% Pass) Which of the following does not impact the content or format of health record documentation? -Paper records -Electronic health records -Type of healthcare setting -Demographic information - Answer️️ -Demographic information What document would be the best place to find information about the morphology of a specimen that was removed during a surgical procedure? -Operative report -Consultation report -Pathology report -Dis...