Reference no: EM133445785
Finding the correct CDIM-10-CM or diagnosis code(s) for the encounter will be the most frustrating thing that you will need to be able tot do in this class. When coding, you will first need to identify the correct index in the CDIM-10-CM code book. Once you do this, you will need to start looking up the code. Most of the time, you will start looking up the code by looking for the main term in a diagnosis for a particular encounter. The following in-class assignments are to acclimate you to understanding the idea of identifying the main term in a diagnosis. If there is a medical term or a word that you are not familiar with, research it, you are in a lab.
Example 1
Acute Cystitis without Hematuria
Acute = refers conditions are severe and sudden. Acute is a descriptor of the condition and is not the main term.
Without Hematuria = Hematuria refers to blood in urine and "without hematuria" is just another way of saying that the patient is showing this symptom. Without hematuria is a descriptor of a symptom that may preside in patients that have this condition-it is not the main condition and thus not the main term.
Cystitis = An infection in any part of the urinary system, the kidneys, bladder, or urethra. This is the condition the is causing the patient pain, the main reason why they came in to see the physician and it is the main term.
Example 2
Inflammation of the jaw
Jaw: is the anatomical site, or the location that is being affected and is not the main term.
Inflammation: condition where part of the body becomes reddened, swollen, hot, and often painful. However, this is due to an injury and infection. If the physician notes state the injury or infection, you would need to for these factors as well (we will learn more about this in chapters 5 and 16). However, based on the information, inflammation would be the main reason why the patient has come to the physician, it is only information listed for the encounter, so it is the main term.
1. Research online and explain what is Pulmonary Necrosis
2. What is the main term here:
Pulmonary Necrosis
3. Research and define:
Chronic Daily Headaches
4. What is the main term here:
Chronic Daily Headaches
5. Research and define:
Adrenal Fibrosis
6. What is the main term here:
Adrenal Fibrosis