CADS Medical Terminology & Clinical Coding Flashcards

Which ICD-10-CM code category is used to document dyspnea as the primary complaint in an ambulance patient care report?

Answer: R06

ICD-10-CM category R06 covers abnormalities of breathing, including dyspnea, which is the appropriate code for respiratory complaints in PCR documentation.

The abbreviation 'AMS' in EMS documentation refers to which clinical finding?

Answer: Altered Mental Status

AMS stands for Altered Mental Status, a common clinical finding documented in EMS patient care reports when a patient's level of consciousness is abnormal.

When documenting a patient with ST-elevation myocardial infarction, which ICD-10-CM code block applies?

Answer: I21

ICD-10-CM code block I21 covers ST-elevation myocardial infarction (STEMI), the appropriate classification for acute heart attack with ST changes.

Which medical term correctly describes the documentation finding 'absence of breath sounds on one side'?

Answer: Unilateral absence of breath sounds

Unilateral absence of breath sounds is the correct clinical term used in documentation when breath sounds are not heard on one side, often indicating pneumothorax or hemothorax.

In NEMSIS-compliant documentation, the element 'ePatient.13' captures which data point?

Answer: Patient's date of birth

NEMSIS element ePatient.13 captures the patient's date of birth, a required demographic field in standardized EMS electronic patient care records.

Which CPT code range covers basic life support (BLS) ambulance services?

Answer: A0428–A0429

HCPCS codes A0428 (BLS non-emergency) and A0429 (BLS emergency) are the correct codes for documenting and billing basic life support ambulance transport.