Term
| The __ of inpatient admission __ govern the selection of __ diagnosis. |
|
Definition
-circumstances
-always
-principal |
|
|
Term
| What is the UHDDS definition of principal diagnosis? |
|
Definition
| That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. |
|
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Term
| Codes for __, __ and __ conditions from Chapter __ are not to be used as __ when a related definitive diagnosis has been established. |
|
Definition
-signs
-symptoms
-ill defined
-18
-principal diagnosis |
|
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Term
| In the usual instance when two or more diagnoses __ meet the criteria for principal diagnosis as determined by the __, __ and/or __, and the Alphabetic Index, Tabular List, or another coding guideline does not provide __, __ of the diagnoses may be sequenced first. |
|
Definition
-equally
-circumstances of admission
-diagnostic workup
-therapy provided
-sequencing direction
-any one |
|
|
Term
| When the admission is for treatment of a __ resulting from __ or other __, the complication code is sequenced as the __. If the complication is classified to the T80-T88 series and the code __ the necessary specificity in describing the complication, an additional code for the __ should be assigned. |
|
Definition
-complication
-surgery
-medical care
-principal diagnosis
-lacks
-specific complication |
|
|
Term
| If the diagnosis documented ____ is qualified as "probable", "suspected", "likely", "questionable", "possible" or "___", or other similar terms indicating uncertainty, code the condition as if it existed or was established. |
|
Definition
-at the time of discharge
-still to be ruled out |
|
|
Term
| For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring what 5 things? |
|
Definition
-clinical evaluation
-therapeutic treatment
-diagnostic procedures
-extended length of hospital stay
-increased nursing care/monitoring |
|
|
Term
| If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should __ be coded. Some providers include in the diagnostic statement __ conditions or diagnoses and __ procedures from __ admissions that have no bearing on the current stay. Such conditions are __ to be reported and are coded only if required by hospital policy. However, __codes (categories Z80-Z87) may be used as secondary codes if the __ condition or __ history has an __ on current care or __ treatment. |
|
Definition
-ordinarily
-resolved
-status-post
-previous
-not
-history
-historical
-family
-impact
-influences |
|
|
Term
| __ findings (laboratory, x-ray, pathologic, and other diagnostic results) are __ coded and reported unless the provider __. If the findings are outside the normal range and the __ has ordered other tests to __ the condition or prescribed __, it is appropriate to ask __ whether the abnormal finding should be added. |
|
Definition
-Abnormal
-not
-indicates their clinical significance
-attending provider
-evaluate
-treatment
-the provider |
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