Medical Coding: Principles, Guidelines, and Case Studies

Running head: Medical coding
Medical coding
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MEDICAL CODING1
1.Explain what the principal or first-listed diagnosis is for a hospital admission.
For getting admitted in a hospital there is a need for specific illness or injury through
which diagnosis and treatment can follow and this is a basic principle for getting admitted.
2.What does abstracting the physician's notes mean?
A physician note consists of the medical details and diagnostic process of the patient
which is vital for the treatment (Gottlieb). In this context abstracting from the physicians note
mean to analyse the information for potential use for a specific illness.
3.Explain the difference between co-morbidities and manifestations.
Comorbidity is related medical term which states the condition when there is an
occurrence of more than one condition in a person. For instance social anxiety and major
depression if found together in a person it is known as comorbidity. Clinical manifestations
are a form of symptoms presented in a person as a result (Zeng et al.) of one single illness and
its effect may vary from moderate to severe. The contrasting difference between the two is
the symptoms where in comorbidity it occurs as a result of interactions of similar disease
while in clinical manifestations symptoms varies.
4.What is an external cause code, and what part of the patient encounter does it tell?
External codes are form of secondary codes especially in injury related and the
guidelines have been especially redone for ICD-10-CM guidelines. These guidelines are
suited for patients with diabetes and gives additional information of the patient injured which
is not reported in other codes and are exclusive.
5.What is the minimum number of codes required to code a sequela or late effect, and in
what sequence or order are they listed?

MEDICAL CODING2
The condition of nature and late effect code are the basic requirements for the
sequential coding of late effect or sequela. There is a requirement of minimum number of two
codes for the sequela coding.
6.What is a Z code, and when would it be assigned?
Z codes are provided in ICD 10 guidelines which is related to health services not
mentioned in other code guidelines (Ogden et al.). The guidelines are special code for first
listed or secondary treatments. Z codes are assigned for special purposes like in specific
illness or in special therapy like radiation therapy or to indicate the status of new borns.
7.Explain the difference in the guidelines between coding for outpatient services and
coding for inpatient services.
In patient coding is more complex than out patient coding as more documentation is
required in outpatient and given more care as they stay in hospital for 24 hours or more. ICD-
9/10-CM guidelines are needed to be followed for both in patient and outpatient coding.
Outpatient coding is more of detailed medical details as there is extended stay as compared to
in patient coding.
8.When is it appropriate to code from the Alphabetic Index?
The alphabetical index is coded to make a procedure code, which would contain all
information. It is always appropriate to always continue with alphabetical index as this
assures efficient procedure.