Health Information & Data Content Flashcards

Which data element in the UB-04 claim form identifies the attending physician?

Answer: Field Locator 76

Field Locator 76 on the UB-04 identifies the attending physician by NPI and name.

A coder notices that the discharge summary is missing from the medical record 24 hours after patient discharge. What is the most appropriate action?

Answer: Query the attending physician for the missing document

The coder should query the attending physician to obtain the missing discharge summary before finalizing the code assignment.

Which Act established national standards for electronic health care transactions and code sets?

Answer: HIPAA

HIPAA (Health Insurance Portability and Accountability Act) established the national standards for electronic transactions and code sets.

What term describes the process of converting verbal or written descriptions of diseases and procedures into numeric or alphanumeric codes?

Answer: Clinical coding

Clinical coding is the process of translating diagnoses, procedures, and services into standardized code sets.

An 'addendum' added to a medical record must include which of the following?

Answer: Date, time, author signature, and reason for the addendum

A proper addendum must include the date, time, author signature, and the reason it was added to maintain record integrity.

In ICD-10-CM, what is the purpose of the 'dummy placeholder' character 'X'?

Answer: To allow future code expansion and meet the 7th character requirement

The placeholder 'X' is used in certain codes to allow for future expansion and to satisfy the requirement of a 7th character.

Which organization maintains the ICD-10-CM code set in the United States?

Answer: CDC's National Center for Health Statistics (NCHS)

The CDC's National Center for Health Statistics (NCHS) is responsible for maintaining the diagnosis portion of ICD-10-CM in the US.