A medical assistant is reviewing the chart of a patient who has arteriosclerotic heart disease. In which of the following references should the assistant look for You are logged in as PAM appropriate diagnostic code?
Physicians' Desk Reference
CPT manual
HCPCS
ICD-10-CM coding manual
The Correct Answer is D
A. Physicians' Desk Reference: The Physicians' Desk Reference (PDR) provides drug information and is not used for diagnostic coding. It includes details about medications, such as their uses, dosages, and side effects.
B. CPT manual: The CPT (Current Procedural Terminology) manual is used to find codes for procedures and services provided by healthcare professionals, not diagnostic codes.
C. HCPCS: The Healthcare Common Procedure Coding System (HCPCS) is primarily used for coding supplies, equipment, and services not included in the CPT manual. It is not used for diagnostic coding.
D. ICD-10-CM coding manual: The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) manual is the correct reference for finding diagnostic codes, including those for arteriosclerotic heart disease.
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Correct Answer is A
Explanation
A. ROM (Rupture of Membranes): ROM is commonly used in obstetrics to describe the rupture of the amniotic sac during labor.
B. LMP (Last Menstrual Period): LMP is used in gynecology and obstetrics, but it is more related to menstrual history rather than obstetric procedures.
C. ADL (Activities of Daily Living): ADL is used in various medical contexts to describe daily living activities, not specific to obstetrics and gynecology.
D. JRA (Juvenile Rheumatoid Arthritis): JRA is unrelated to obstetrics and gynecology; it pertains to a type of arthritis in children.
Correct Answer is D
Explanation
A. The patient reports the receptionist was rude to them. This is not relevant to the patient’s medical care and should not be documented in the health record.
B. The patient states that there is an error on their bill. Billing issues are not related to the clinical care of the patient and should not be documented in the health record.
C. The patient states their insurance might be changing soon. This is administrative information and does not pertain to the clinical aspect of the patient’s care.
D. The patient reports they recently developed a strawberry allergy. This is relevant medical information that could affect the patient’s treatment and should be documented in the health record.