Which of the following procedures should a medical assistant identify as a surgical reconstruction?
A Thoracentesis
Rhinoplasty
Appendectomy
Colotomy
The Correct Answer is B
A. Thoracentesis: Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall; it is not a reconstruction.
B. Rhinoplasty: Rhinoplasty is a surgical reconstruction of the nose, often performed for cosmetic or functional reasons.
C. Appendectomy: Appendectomy is the surgical removal of the appendix, not a reconstructive surgery.
D. Colotomy: Colotomy is the surgical incision into the colon, not a reconstructive procedure.
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Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
A. Subjective: The chief complaint is a patient-reported symptom or concern and is documented in the subjective section of the progress note. This section includes the patient’s personal perspective and descriptions of their symptoms.
B. Objective: The objective section includes measurable or observable data, such as vital signs and physical examination findings, not the patient’s chief complaint.
C. Review of systems: The review of systems is a systematic approach to obtaining information about the functioning of various body systems but is not specifically where the chief complaint is documented.
D. Assessment: The assessment section contains the provider’s diagnostic impressions and conclusions about the patient’s condition, rather than the chief complaint.