When the type of endoscope has not been stated in the medical record does the OPCS-4.6 Tabular List, default to fibreoptic (flexible) or rigid endoscope.?

 

 

  1.  When the type of endoscope has not been stated in the medical record does the OPCS-4.6 Tabular List, default to fibreoptic (flexible) or rigid endoscope.?

 

The default is fibreoptic (flexible)

 

 

 

  1. Briefly describe the coding rule to be applied when an ‘exploratory laparotomy’ results in another procedure being performed during the same theatre visit.

 

When an exploratory laparotomy is performed and another

procedure results from the exploration, it is only necessary to code the other procedure performed.                                     

 

 

  1. What two special symbols can be found in the Neoplasm Table of the ICD-10 Alphabetical Index, Volume 3?

 

Cross hatch or # symbol

Diamond or ¯symbol

 

 

 

  1. How must a hernia be coded when both obstruction and gangrene are present? [Actual codes not required].

 

Hernia with both gangrene and obstruction must be classified to hernia with gangrene

 

 

 

  1. What is the OPCS-4.6 definition of an ‘emergency’ procedure?

 

The term ‘emergency’ pertains to the use of operating theatre time that has not been pre-scheduled (including operations added to a pre-scheduled list).

 

 

 

 

  1. Name in full two of the four specific abbreviations used in the OPCS-

4.6 Tabular List.

 

However Further Qualified

Not Elsewhere Classified

Not Further Qualified

Not Otherwise Classifiable

 

 

  1. Which two personal history problem codes found in the ICD-10 Tabular List, Volume 1 are permissible to be assigned in a primary position?

 

Z85.6 or Personal history of leukaemia

Z85.7 or Personal history of other malignant neoplasms of lymphoid, haematopoietic and related tissues

 

 

  1. What coding rule must be adhered to when a Coronary Artery Bypass Graft (CABG) is performed simultaneously with a procedure on the heart valves?

 

The bypass procedure would be coded in the primary position

 

 

 

  1. What type of code(s) must be recorded on the first day of the first cycle of chemotherapy given to a patient as an outpatient/daycase? [Actual codes not required]

 

Procurement code

Delivery code

 

 

  1. Give three examples of types of ICD-10 codes that would never be used in a primary diagnostic position. [Actual codes not required]

 

Sequelae codes

External cause codes

Supplementary codes such as the range B95-B98

Certain codes from Chapter XXI (Z codes)

Morphology Codes

U80-U89 (Bacterial agents resistant to antibiotics)

 

 

 

 

 

 

 

 

  1. Name the ICD-10 three dimensions of coding accuracy.

 

Individual codes

Totality of codes

Sequencing of codes

 

 

 

  1. What exact position would a code from ICD-10 categories U80- U89 Antibiotic resistant bacteria be assigned?

 

Codes U80-U89 would be sequenced immediately following the                    code for a bacterial infection classified elsewhere.

 

 

 

  1. Is coding of High Cost Drugs completed for each Consultant Episode or the Hospital Provider Spell?

 

(Hospital Provider) Spell

 

 

 

  1. Briefly explain the nature of instructional ‘Excludes’ notes found within the OPCS-4.6 Tabular List, Volume 1.

 

Excludes notes direct the coder away from a code they may be

tempted to use

Exclusion notes includes specific reference to the correct

chapter, (category or subcategory)

 

 

 

  1. What is the coding rule when angioplasty and stent procedures are             performed concurrently and why?

 

It is only necessary to code the stent insertion

This is because the angioplasty is implicit within the code for stent

insertion

 

 

  1. Briefly describe the nature of the ‘Colon’ or ‘:’ punctuation found in ICD-10 Tabular List, Volume 1.

 

A colon is used above a list of bulleted modifiers              The condition or word preceding the colon must be followed by

one of the bulleted modifiers in order for that code to be

assigned

 

 

  1. When both gestational age and birth weight of a premature baby are known, which code(s) require coding and why? [Actual codes not required]

 

Priority of assignment must be given to birth weight

This is because premature gestation is already implied in the    three character category

 

 

 

  1. Briefly describe the coding rule and sequencing position associated with the ICD-10 code R57.2 Septic shock.

 

Whenever septic shock is recorded in the medical record it

must be coded

Code R57.2 can be coded in the primary position or secondary position

 

 

 

  1. Describe in full Step three of the ICD-10 four step coding process.

 

Assign a tentative code(s)  using the Alphabetical Index (Volume

3) taking into account all rules, conventions   and standards

 

 

 

  1. Briefly describe the nature and sequencing rule for paired codes found in the OPCS-4.6 Tabular List, Volume 1.

 

Some interventions frequently carried out together, are coded separately. Where double coding of this nature is necessary, the categories concerned contain instructional notes to indicate

correct sequencing. These Notes also provide the other correct category or code to be used

 

 

Section D – General Theory Questions  

 

Please use separate Answer Sheets found at the end of this question paper, to answer each question in Section D.

 You must use a new Answer Sheet for each question

 Write on only one side of the Answer Sheet

 You must write your candidate number in the top right hand corner of each Answer Sheet that you use

 You must write the question number in the top left hand corner of each Answer Sheet that you use

 

Section D [1] – ICD-10 Theory   [15% of the marks]

 

Answer either Part A or Part B of the following:

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D1 Part A: [Answer all parts of this question i, ii and iii]  

 

  1. i) Name and fully describe the three types of cross references found in the ICD-10 Alphabetical Index, Volume 3.

 

See                                                                                             

This cross reference is an explicit direction to look elsewhere as no codes can be found alongside this reference. It is used to direct the coder to another term in the Alphabetical Index where complete information can be found. It is also used after anatomical sites to remind coders that the Alphabetical Index is organised by condition.

 

See also

This cross reference reminds coders to look under another lead term if the first term they are looking for cannot be found modified in any way under the first lead term.

 

See category

This cross reference directs the coder to a specific threecharacter category in the Tabular List where more important

information governing the use of that category is located

 

 

 

 

 

 

 

 

 

  1. ii) Describe four circumstances where the convention of ‘Parentheses’ are used in the ICD-10 Tabular List, Volume 1.

 

Parentheses are used to enclose supplementary words,

(nonessential modifiers) which may follow a diagnostic term

without affecting the code assignment

Parentheses are also used to enclose the code to which an exclusion term refers

Parentheses are used in the block titles, to ensure the threecharacter codes of categories are included in that block

 

Parentheses are used to enclose the dagger code in an asterisk

category or the asterisk code following a dagger term

Parentheses are used in chapter levels to display the threecharacter codes of that chapter

 

 

iii)         Describe the ICD-10 coding guidance for the use of ‘Sequelae’ codes.

 

Sequelae (or late effect) codes are for use when the current condition or disease has been caused by a previous disease   which has been treated and is therefore no longer present   Sequelae codes must only ever be assigned in a secondary position

 

OR

 

Question D1 Part B: [Answer all parts of this question i, ii and iii]

 

  1. Describe the purpose, selection and sequencing rules of the ICD-10 classification dagger and asterisk system.

 

  • Provides dual classification for diagnostic statements
  • This includes the aetiology or underlying disease and associated manifestation
  • The underlying disease is marked with a dagger
  • The manifestation of the disease is marked with an asterisk

 

  • The ICD-10 4th Edition states the dagger and asterisk sequence may be reversed depending on the main condition treated

 

  • Each asterisk code must have its own dagger code

 

  • Where the responsible consultant has not specified which is the main condition being treated the dagger asterisk default must be

used i.e. the dagger code must be assigned in the primary position followed by the asterisk code

  • Any code has the potential to be used as a dagger code

 

 

 

  1. For the purpose of clinical coding, what is the definition of a co-morbidity?

 

A co-morbidity is any condition which co-exists in conjunction with another disease that is currently being treated at the time of admission or develops subsequently  and that affects the management of the patient’s current consultant episode.

 

  • Briefly describe three of the possible six scenarios when it would be permissible to use an ICD-10 sign or symptom code.

 

A more specific diagnosis cannot be made even after full

investigation

They are transient (temporary or passing) and the cause could

not be determined

They record a provisional diagnosis in a patient who failed to

have further investigation

The case is referred elsewhere for investigation or treatment

before a diagnosis was made

A more precise diagnosis was not available for any other reason

 

The cause of the symptoms and signs is known, but they are important problems in medical care requiring treatment The symptoms and signs must be recorded in a secondary position, in addition to the known cause due to specific guidance Section D [2] – OPCS-4 Theory [15% of the marks]

 

Answer either Part A or Part B of the following: 

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D2 Part A: [Answer all parts of this question i, ii and iii]

 

 

  1. Name the four levels of complexity of interventions as referenced within the OPCS-4.6 Clinical Coding Instruction Manual (Version 4.0).

 

Major

Intermediate

Minor

Non-operative procedures

 

  1. Name the five different types of resources that might affect code

assignment when coding radiological examinations within the OPCS-             4.6 code range Y97 Radiology with contrast and Y98 Radiology              procedures.

 

Number of areas of examination(s)                              

Usage of contrast media                                                             

Duration of procedure                                                     

Extensive repositioning                                                              

Mobile and intra-operative procedures                                    

 

 

 

 

  • Name four of the nine diagnostic imaging procedures which must always be coded when performed on inpatient episodes of care. [Actual codes not required]

 

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT)

Positron Emission Tomography (PET) scans

 

Implantation of electrocardiography loop recorder (Reveal loop recorder)

Removal of electrocardiography loop recorder

Transthoracic echocardiography (TTE)

Transoesophageal echocardiography (TOE)

Intravascular echocardiography

Epicardial echocardiography

 

 

                                                      OR

 

Question D2 Part B: [Answer all parts of this question i, ii and iii]

 

 

  1. i) Describe the nature and sequencing of codes when different types of scans take place during the same visit to the Radiology Department.

 

When more than one area is scanned using either the same or different scans during a single visit to the radiology department the coder must default to the specific fourth character from category U21, or Diagnostic imaging procedures (U21) or category U36, or Other diagnostic imaging (U36)

 

Followed by a code from category Y97, or (Y97) Radiology with

contrast (if applicable)

Followed then by a code from category Y98, or (Y98) Radiology procedures with correct fourth character

 

Lastly the relevant site code from Chapter Z

 

 

 

(ii) Briefly describe and explain the purpose of ‘Principal’ and ‘Extended’ categories that are found within the OPCS-4.6 classification.

 

These have been introduced within the Tabular List when all  possible four-digit codes had been used at a particular three-digit category, but additional procedures need to be classified to that category

Extended categories are an extension to a ‘principal’ category

 

Extended categories have very similar titles to their principal category

Extended categories are not always in numerical order (but have

sometimes) been slotted into gaps within the classification

 

The .8 and .9 subcategories at the extended category must  never be used. If a .8 or .9 is required it must be assigned from

the principal category

There are notes at the three-character categories to identify the principal category and the extended category                                       (iii)      What types of codes are required, and how must they be sequenced, when a therapeutic endoscopic procedure is performed and a biopsy is taken at the same time during the same theatre visit? [Actual codes not required]

 

Assign a code from the relevant therapeutic endoscopy category

for the therapeutic procedure

Assign a code from category (Y20 Biopsy of organ NOC) for the

biopsy

 

If the site of the biopsy is different to that specified in the main

procedure code, assign the relevant code from Chapter Z for the site of the biopsy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D [3] – Clinical Terms [10% of the marks]

 

Answer either Part A or Part B of the following:  

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D3 Part A [Answer all parts of this question i, ii and iii]

 

 

  • Give a brief description of the following components of a SNOMED CT concept:

 

Fully Specified Name

Preferred Term

Synonym

 

 

Fully Specified Name – provides an unambiguous way of naming a concept

Preferred term – the most common word or phrase used by clinicians to name a concept

Synonym – the rest of the names that might be used for a concept

 

 

  • The cross-mapping methodology uses a series of flags to apply standards, rules and conventions of the ICD-10 and OPCS-4.6 classifications. Give three examples of a standard or rule or convention found within one of these classifications.

 

Examples include:

Dagger and asterisk system                                             

Sequencing rules

Conventions such as ‘See also’

 

 

  • Name the two types of ‘relationships’ a SNOMED CT concept can have.

 

IS_A

Attribute

 

 

 

 

 

 

 

 

                                                                  OR

      

Question D3 Part B [Answer all parts of this question, i, ii and iii]

 

 

  • Give the full names of the two original source terminologies used in the development of the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).

 

SNOMED RT or Systematized Nomenclature of Medicine

Reference Terminology

Read Codes Version 3 or Clinical Terms Version 3

 

 

  • List three possible drivers for additions or changes to the cross-maps between SNOMED CT and the classifications that are used by the NHS.

 

 

World Health Organisation updates to ICD-10                                                   

Updates or revisions of OPCS-4   

Requests from the NHS                                                  

Output from the UK Coding Review Panel (Coding Clinics)

Changes in support of department of Health initiatives

New content in SNOMED CT

                                                                 

 

  • SNOMED CT is the chosen clinical terminology for the NHS in England. What is a ‘clinical terminology’ and what areas does it cover?

 

It is a structured collection of terms

These terms describe the care and treatment of patients  Covers areas such as diagnosis, symptoms, surgical   procedures, treatments and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D [4] – Miscellaneous Section[5% of the marks]

 

Answer either Part A or Part B of the following: 

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D4 Part A: [Answer this question]

 

  1. i) Name and describe the two types of modifiers which appear in the ICD-10 Alphabetical Index, Volume 3.

 

Nonessential modifiers are descriptors which do not affect the code selection they appear in parentheses (curly or round brackets) and are in bold face following the terms they modify.

 

Essential modifiers are descriptive terms which do affect code selection. These modifiers describe essential differences  and appear as subterms indented below lead terms (in Alphabetical order).

 

                                                           OR

 

Question D4 Part B: [Answer parts i and ii of this question]

 

  1. i) List the six components that a regimen describes according to guidance found in the Chemotherapy Regimen Clinical Coding Guidance – OPCS-4.6 (April 2013-14 V3.1)

 

A regimen describes:

 

  • the full name of the regimen
  • the drugs involved
  • the doses of the drugs
  • the routes of administration
  • time of delivery
  • sometimes the number of repetitions or cycles

 

 

  1. ii) Name the twofact’ codes which are mandatory to record from Chapter XXI Factors influencing health status and contact with the health service that are not representative of a ‘service’ or ‘problem’.

 

Z37 or Outcome of delivery

Z38 or Liveborn infants according to place of birth

 

 

 

 

 

 

SECTION E          –    Anatomy & Physiology (including Medical Terminology)   [35% of the marks]

 

Please be aware that spelling will be taken into account during the marking process.

 

Section E [1] – Anatomy & Physiology

 

Answer ALL 15 questions in this Section, writing your answers in the spaces  provided.

 

  1. How many lobes does the left lung contain?

 

2 (Lobes)                                                                      

 

 

  1. What is the medical term for the contraction stage of the cardiac cycle?

 

Systole                                                                       

 

 

  1. Name the three main types of muscle tissue.

 

Voluntary (striated or skeletal)

Involuntary (smooth)

Cardiac

 

 

  1. Name the tubes which extend from each of the kidneys to the bladder that convey urine.

 

Ureters

 

 

 

  1. Each hemisphere of the cerebrum is divided into lobes. Name the four

Frontal (lobe)

Occipital (lobe)

Parietal (lobe)

Temporal (lobe)

 

 

  1. Name the five pairs of spinal nerves which are associated with the five areas of the vertebral column.

 

Cervical (nerves)

Thoracic (nerves)

Lumbar (nerves)

Sacral (nerves)

Coccygeal (nerves)

 

  1. What shape is the ‘Tympanic membrane’ (Ear drum)?

 

Oval

 

 

 

  1. Skin colour is affected by which three main factors?

 

Melanin

The level of oxygenation and amount of blood circulating

in the dermis

Bile pigments in blood and carotene in subcutaneous fat

 

 

 

  1. Name the circular muscle that controls the opening of the anus.

 

(Anal) sphincter

 

 

  1. Name four of the 12 pairs of cranial nerves which originate from the

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducent

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossal

 

 

 

  1. Name the gas, formed in tissue cells, which is a by-product of

 

Carbon dioxide (C02)

 

 

 

  1. Name the strongest and largest bone in the human body.

 

Femur or thigh bone                                    

 

 

 

 

 

  1. What is a ‘medullary canal’ and what does it contain?

 

A hollow in the centre of a long bone

Contains bone marrow

 

 

 

  1. What is the collective term given to the malleus, incus and stapes?

 

Ossicular chain or Auditory ossicles

 

 

 

  1. How many carpal bones form each wrist joint?

 

8 Carpal bones in each wrist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please be aware spelling will be taken into account during the marking process.

 

Section E [2] – Medical Terminology

 

Answer ALL 10 questions in this Section, writing your answers in the spaces provided.

 

 

  1. Circle the four prefixes in the list below:

 

  sub chol desis
  aden pexy trans
  hemi ec tripsy

 

 

 

  1. Describe the active or passive circular movement of a limb.

 

Circumduction

 

 

 

  1. Name the four components that make up a medical term.

 

Root word

Prefix

Suffix

Combining vowel(s)

 

 

  1. What is the meaning of the root word ‘Ost’?

 

Bone

 

 

  1. What is the root word that means joint?

 

Arthr

 

 

  1. The ending that follows a root word is known as what?

 

Suffix

 

 

  1. What does the medical term ‘Ectopic pregnancy’ denote?

 

(Gestation) outside of the uterine cavity

 

 

  1. Physiology is the study of what?

 

How the body functions

 

 

  1. ‘Anterior’ views describe which body views?

 

Views of the front of the body

 

 

  1. What is the prefix in the term ‘Abnormal’?

 

Ab

 

 

 

 

 

Section E [3] Diagrams

Precisely label the anatomical structure indicated by each line on the following two diagrams. Write your answers in the boxes below.

 

E 3 [a] Hip Joint

 

 

 

 

 

1. Pelvic bone  6. Neck of femur
2. Pubis  7. Lesser trochanter 
3. Ischium  8. Greater trochanter 
4. Ilium  9. Shaft of femur 
5. Head of Femur     

 

 

 

 

 

 

E 3 [b] Name the following muscles

 

 

 

 

Orbicularis oculi  6 Brachioradialis 
Deltoid  7 Sternocleidomastoid 
Pectoralis major  8 Trapezius 
Biceps brachii  9 Latissimus dorsi 
Rectus abdominis  10 Triceps brachii  

 

onal Clinical Coding Examination [UK]

 

25 March 2014

 

Paper 2 Theory

 

1:30pm – 4:35pm

[THREE HOURS]

 

The first 5 minutes will be spent reading through this Examination Paper

 

Instructions to Candidates

 

 Write your Candidate Number at the top of each Answer Sheet of paper.  If you do not enter your Candidate Number the work will not be marked.

 Please make sure you cross out any rough work or any mistakes which you have made.

 You may not use ICD-10 or OPCS-4, dictionaries or any other books or documents for this paper.

 Spelling will be taken into account during the marking process.

 For Section D indicate clearly which question you have answered.  All papers must be handed in to the invigilator.

 

This Examination Paper consists of 3 sections: C, D and E.

Section C General Short Theory Questions [20% of the marks] Answer all questions in the spaces provided on the Examination Paper.

 

Section D [45% of the marks]

Answer all questions on the lined paper provided. Use a new sheet of paper for each answer.  Write only on one side of the paper.

 

General Theory ICD-10 Questions D1 [15% of the marks]

Answer either D1A or D1B

General Theory OPCS-4 Questions D2 [15% of the marks]

Answer either D2A or D2B

Clinical Terms Questions D3 [10% of the marks]

Answer either D3A or D3B

Miscellaneous Questions D4 [5% of the marks]

Answer either D4A or D4B

 

Section E Anatomy and Physiology (including Medical Terminology)

[35% of the marks]

Answer all questions in the spaces provided on the Examination Paper.

 

March 2014 Theory Answers Page 1

ANSWERS 

 

Section C – General Theory Short Questions [20% of the marks]

 

Answer ALL 20 questions in this Section writing your answers in the spaces provided.

 

 

  1. When the type of endoscope has not been stated in the medical record does the OPCS-4.6 Tabular List, default to fibreoptic (flexible) or rigid endoscope.?

 

The default is fibreoptic (flexible)

 

 

 

  1. Briefly describe the coding rule to be applied when an ‘exploratory laparotomy’ results in another procedure being performed during the same theatre visit.

 

When an exploratory laparotomy is performed and another

procedure results from the exploration, it is only necessary to code the other procedure performed.                                     

 

 

  1. What two special symbols can be found in the Neoplasm Table of the ICD-10 Alphabetical Index, Volume 3?

 

Cross hatch or # symbol

Diamond or ¯symbol

 

 

 

  1. How must a hernia be coded when both obstruction and gangrene are present? [Actual codes not required].

 

Hernia with both gangrene and obstruction must be classified to hernia with gangrene

 

 

 

  1. What is the OPCS-4.6 definition of an ‘emergency’ procedure?

 

The term ‘emergency’ pertains to the use of operating theatre time that has not been pre-scheduled (including operations added to a pre-scheduled list).

 

 

 

 

  1. Name in full two of the four specific abbreviations used in the OPCS-

4.6 Tabular List.

 

However Further Qualified

Not Elsewhere Classified

Not Further Qualified

Not Otherwise Classifiable

 

 

  1. Which two personal history problem codes found in the ICD-10 Tabular List, Volume 1 are permissible to be assigned in a primary position?

 

Z85.6 or Personal history of leukaemia

Z85.7 or Personal history of other malignant neoplasms of lymphoid, haematopoietic and related tissues

 

 

  1. What coding rule must be adhered to when a Coronary Artery Bypass Graft (CABG) is performed simultaneously with a procedure on the heart valves?

 

The bypass procedure would be coded in the primary position

 

 

 

  1. What type of code(s) must be recorded on the first day of the first cycle of chemotherapy given to a patient as an outpatient/daycase? [Actual codes not required]

 

Procurement code

Delivery code

 

 

  1. Give three examples of types of ICD-10 codes that would never be used in a primary diagnostic position. [Actual codes not required]

 

Sequelae codes

External cause codes

Supplementary codes such as the range B95-B98

Certain codes from Chapter XXI (Z codes)

Morphology Codes

U80-U89 (Bacterial agents resistant to antibiotics)

 

 

 

 

 

 

 

 

  1. Name the ICD-10 three dimensions of coding accuracy.

 

Individual codes

Totality of codes

Sequencing of codes

 

 

 

  1. What exact position would a code from ICD-10 categories U80- U89 Antibiotic resistant bacteria be assigned?

 

Codes U80-U89 would be sequenced immediately following the                    code for a bacterial infection classified elsewhere.

 

 

 

  1. Is coding of High Cost Drugs completed for each Consultant Episode or the Hospital Provider Spell?

 

(Hospital Provider) Spell

 

 

 

  1. Briefly explain the nature of instructional ‘Excludes’ notes found within the OPCS-4.6 Tabular List, Volume 1.

 

Excludes notes direct the coder away from a code they may be

tempted to use

Exclusion notes includes specific reference to the correct

chapter, (category or subcategory)

 

 

 

  1. What is the coding rule when angioplasty and stent procedures are             performed concurrently and why?

 

It is only necessary to code the stent insertion

This is because the angioplasty is implicit within the code for stent

insertion

 

 

  1. Briefly describe the nature of the ‘Colon’ or ‘:’ punctuation found in ICD-10 Tabular List, Volume 1.

 

A colon is used above a list of bulleted modifiers              The condition or word preceding the colon must be followed by

one of the bulleted modifiers in order for that code to be

assigned

 

 

  1. When both gestational age and birth weight of a premature baby are known, which code(s) require coding and why? [Actual codes not required]

 

Priority of assignment must be given to birth weight

This is because premature gestation is already implied in the    three character category

 

 

 

  1. Briefly describe the coding rule and sequencing position associated with the ICD-10 code R57.2 Septic shock.

 

Whenever septic shock is recorded in the medical record it

must be coded

Code R57.2 can be coded in the primary position or secondary position

 

 

 

  1. Describe in full Step three of the ICD-10 four step coding process.

 

Assign a tentative code(s)  using the Alphabetical Index (Volume

3) taking into account all rules, conventions   and standards

 

 

 

  1. Briefly describe the nature and sequencing rule for paired codes found in the OPCS-4.6 Tabular List, Volume 1.

 

Some interventions frequently carried out together, are coded separately. Where double coding of this nature is necessary, the categories concerned contain instructional notes to indicate

correct sequencing. These Notes also provide the other correct category or code to be used

 

 

Section D – General Theory Questions  

 

Please use separate Answer Sheets found at the end of this question paper, to answer each question in Section D.

 You must use a new Answer Sheet for each question

 Write on only one side of the Answer Sheet

 You must write your candidate number in the top right hand corner of each Answer Sheet that you use

 You must write the question number in the top left hand corner of each Answer Sheet that you use

 

Section D [1] – ICD-10 Theory   [15% of the marks]

 

Answer either Part A or Part B of the following:

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D1 Part A: [Answer all parts of this question i, ii and iii]  

 

  1. i) Name and fully describe the three types of cross references found in the ICD-10 Alphabetical Index, Volume 3.

 

See                                                                                             

This cross reference is an explicit direction to look elsewhere as no codes can be found alongside this reference. It is used to direct the coder to another term in the Alphabetical Index where complete information can be found. It is also used after anatomical sites to remind coders that the Alphabetical Index is organised by condition.

 

See also

This cross reference reminds coders to look under another lead term if the first term they are looking for cannot be found modified in any way under the first lead term.

 

See category

This cross reference directs the coder to a specific threecharacter category in the Tabular List where more important

information governing the use of that category is located

 

 

 

 

 

 

 

 

 

  1. ii) Describe four circumstances where the convention of ‘Parentheses’ are used in the ICD-10 Tabular List, Volume 1.

 

Parentheses are used to enclose supplementary words,

(nonessential modifiers) which may follow a diagnostic term

without affecting the code assignment

Parentheses are also used to enclose the code to which an exclusion term refers

Parentheses are used in the block titles, to ensure the threecharacter codes of categories are included in that block

 

Parentheses are used to enclose the dagger code in an asterisk

category or the asterisk code following a dagger term

Parentheses are used in chapter levels to display the threecharacter codes of that chapter

 

 

iii)         Describe the ICD-10 coding guidance for the use of ‘Sequelae’ codes.

 

Sequelae (or late effect) codes are for use when the current condition or disease has been caused by a previous disease   which has been treated and is therefore no longer present   Sequelae codes must only ever be assigned in a secondary position

 

OR

 

Question D1 Part B: [Answer all parts of this question i, ii and iii]

 

  1. Describe the purpose, selection and sequencing rules of the ICD-10 classification dagger and asterisk system.

 

  • Provides dual classification for diagnostic statements
  • This includes the aetiology or underlying disease and associated manifestation
  • The underlying disease is marked with a dagger
  • The manifestation of the disease is marked with an asterisk

 

  • The ICD-10 4th Edition states the dagger and asterisk sequence may be reversed depending on the main condition treated

 

  • Each asterisk code must have its own dagger code

 

  • Where the responsible consultant has not specified which is the main condition being treated the dagger asterisk default must be

used i.e. the dagger code must be assigned in the primary position followed by the asterisk code

  • Any code has the potential to be used as a dagger code

 

 

 

  1. For the purpose of clinical coding, what is the definition of a co-morbidity?

 

A co-morbidity is any condition which co-exists in conjunction with another disease that is currently being treated at the time of admission or develops subsequently  and that affects the management of the patient’s current consultant episode.

 

  • Briefly describe three of the possible six scenarios when it would be permissible to use an ICD-10 sign or symptom code.

 

A more specific diagnosis cannot be made even after full

investigation

They are transient (temporary or passing) and the cause could

not be determined

They record a provisional diagnosis in a patient who failed to

have further investigation

The case is referred elsewhere for investigation or treatment

before a diagnosis was made

A more precise diagnosis was not available for any other reason

 

The cause of the symptoms and signs is known, but they are important problems in medical care requiring treatment The symptoms and signs must be recorded in a secondary position, in addition to the known cause due to specific guidance Section D [2] – OPCS-4 Theory [15% of the marks]

 

Answer either Part A or Part B of the following: 

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D2 Part A: [Answer all parts of this question i, ii and iii]

 

 

  1. Name the four levels of complexity of interventions as referenced within the OPCS-4.6 Clinical Coding Instruction Manual (Version 4.0).

 

Major

Intermediate

Minor

Non-operative procedures

 

  1. Name the five different types of resources that might affect code

assignment when coding radiological examinations within the OPCS-             4.6 code range Y97 Radiology with contrast and Y98 Radiology              procedures.

 

Number of areas of examination(s)                              

Usage of contrast media                                                             

Duration of procedure                                                     

Extensive repositioning                                                              

Mobile and intra-operative procedures                                    

 

 

 

 

  • Name four of the nine diagnostic imaging procedures which must always be coded when performed on inpatient episodes of care. [Actual codes not required]

 

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT)

Positron Emission Tomography (PET) scans

 

Implantation of electrocardiography loop recorder (Reveal loop recorder)

Removal of electrocardiography loop recorder

Transthoracic echocardiography (TTE)

Transoesophageal echocardiography (TOE)

Intravascular echocardiography

Epicardial echocardiography

 

 

                                                      OR

 

Question D2 Part B: [Answer all parts of this question i, ii and iii]

 

 

  1. i) Describe the nature and sequencing of codes when different types of scans take place during the same visit to the Radiology Department.

 

When more than one area is scanned using either the same or different scans during a single visit to the radiology department the coder must default to the specific fourth character from category U21, or Diagnostic imaging procedures (U21) or category U36, or Other diagnostic imaging (U36)

 

Followed by a code from category Y97, or (Y97) Radiology with

contrast (if applicable)

Followed then by a code from category Y98, or (Y98) Radiology procedures with correct fourth character

 

Lastly the relevant site code from Chapter Z

 

 

 

(ii) Briefly describe and explain the purpose of ‘Principal’ and ‘Extended’ categories that are found within the OPCS-4.6 classification.

 

These have been introduced within the Tabular List when all  possible four-digit codes had been used at a particular three-digit category, but additional procedures need to be classified to that category

Extended categories are an extension to a ‘principal’ category

 

Extended categories have very similar titles to their principal category

Extended categories are not always in numerical order (but have

sometimes) been slotted into gaps within the classification

 

The .8 and .9 subcategories at the extended category must  never be used. If a .8 or .9 is required it must be assigned from

the principal category

There are notes at the three-character categories to identify the principal category and the extended category                                       (iii)      What types of codes are required, and how must they be sequenced, when a therapeutic endoscopic procedure is performed and a biopsy is taken at the same time during the same theatre visit? [Actual codes not required]

 

Assign a code from the relevant therapeutic endoscopy category

for the therapeutic procedure

Assign a code from category (Y20 Biopsy of organ NOC) for the

biopsy

 

If the site of the biopsy is different to that specified in the main

procedure code, assign the relevant code from Chapter Z for the site of the biopsy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D [3] – Clinical Terms [10% of the marks]

 

Answer either Part A or Part B of the following:  

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D3 Part A [Answer all parts of this question i, ii and iii]

 

 

  • Give a brief description of the following components of a SNOMED CT concept:

 

Fully Specified Name

Preferred Term

Synonym

 

 

Fully Specified Name – provides an unambiguous way of naming a concept

Preferred term – the most common word or phrase used by clinicians to name a concept

Synonym – the rest of the names that might be used for a concept

 

 

  • The cross-mapping methodology uses a series of flags to apply standards, rules and conventions of the ICD-10 and OPCS-4.6 classifications. Give three examples of a standard or rule or convention found within one of these classifications.

 

Examples include:

Dagger and asterisk system                                             

Sequencing rules

Conventions such as ‘See also’

 

 

  • Name the two types of ‘relationships’ a SNOMED CT concept can have.

 

IS_A

Attribute

 

 

 

 

 

 

 

 

                                                                  OR

      

Question D3 Part B [Answer all parts of this question, i, ii and iii]

 

 

  • Give the full names of the two original source terminologies used in the development of the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).

 

SNOMED RT or Systematized Nomenclature of Medicine

Reference Terminology

Read Codes Version 3 or Clinical Terms Version 3

 

 

  • List three possible drivers for additions or changes to the cross-maps between SNOMED CT and the classifications that are used by the NHS.

 

 

World Health Organisation updates to ICD-10                                                   

Updates or revisions of OPCS-4   

Requests from the NHS                                                  

Output from the UK Coding Review Panel (Coding Clinics)

Changes in support of department of Health initiatives

New content in SNOMED CT

                                                                 

 

  • SNOMED CT is the chosen clinical terminology for the NHS in England. What is a ‘clinical terminology’ and what areas does it cover?

 

It is a structured collection of terms

These terms describe the care and treatment of patients  Covers areas such as diagnosis, symptoms, surgical   procedures, treatments and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D [4] – Miscellaneous Section[5% of the marks]

 

Answer either Part A or Part B of the following: 

 

Please use a separate Answer Sheet making it clear which question you are answering and label each Section accordingly.

 

Question D4 Part A: [Answer this question]

 

  1. i) Name and describe the two types of modifiers which appear in the ICD-10 Alphabetical Index, Volume 3.

 

Nonessential modifiers are descriptors which do not affect the code selection they appear in parentheses (curly or round brackets) and are in bold face following the terms they modify.

 

Essential modifiers are descriptive terms which do affect code selection. These modifiers describe essential differences  and appear as subterms indented below lead terms (in Alphabetical order).

 

                                                           OR

 

Question D4 Part B: [Answer parts i and ii of this question]

 

  1. i) List the six components that a regimen describes according to guidance found in the Chemotherapy Regimen Clinical Coding Guidance – OPCS-4.6 (April 2013-14 V3.1)

 

A regimen describes:

 

  • the full name of the regimen
  • the drugs involved
  • the doses of the drugs
  • the routes of administration
  • time of delivery
  • sometimes the number of repetitions or cycles

 

 

  1. ii) Name the twofact’ codes which are mandatory to record from Chapter XXI Factors influencing health status and contact with the health service that are not representative of a ‘service’ or ‘problem’.

 

Z37 or Outcome of delivery

Z38 or Liveborn infants according to place of birth

 

 

 

 

 

 

SECTION E          –    Anatomy & Physiology (including Medical Terminology)   [35% of the marks]

 

Please be aware that spelling will be taken into account during the marking process.

 

Section E [1] – Anatomy & Physiology

 

Answer ALL 15 questions in this Section, writing your answers in the spaces  provided.

 

  1. How many lobes does the left lung contain?

 

2 (Lobes)                                                                      

 

 

  1. What is the medical term for the contraction stage of the cardiac cycle?

 

Systole                                                                       

 

 

  1. Name the three main types of muscle tissue.

 

Voluntary (striated or skeletal)

Involuntary (smooth)

Cardiac

 

 

  1. Name the tubes which extend from each of the kidneys to the bladder that convey urine.

 

Ureters

 

 

 

  1. Each hemisphere of the cerebrum is divided into lobes. Name the four

Frontal (lobe)

Occipital (lobe)

Parietal (lobe)

Temporal (lobe)

 

 

  1. Name the five pairs of spinal nerves which are associated with the five areas of the vertebral column.

 

Cervical (nerves)

Thoracic (nerves)

Lumbar (nerves)

Sacral (nerves)

Coccygeal (nerves)

 

  1. What shape is the ‘Tympanic membrane’ (Ear drum)?

 

Oval

 

 

 

  1. Skin colour is affected by which three main factors?

 

Melanin

The level of oxygenation and amount of blood circulating

in the dermis

Bile pigments in blood and carotene in subcutaneous fat

 

 

 

  1. Name the circular muscle that controls the opening of the anus.

 

(Anal) sphincter

 

 

  1. Name four of the 12 pairs of cranial nerves which originate from the

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducent

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossal

 

 

 

  1. Name the gas, formed in tissue cells, which is a by-product of

 

Carbon dioxide (C02)

 

 

 

  1. Name the strongest and largest bone in the human body.

 

Femur or thigh bone                                    

 

 

 

 

 

  1. What is a ‘medullary canal’ and what does it contain?

 

A hollow in the centre of a long bone

Contains bone marrow

 

 

 

  1. What is the collective term given to the malleus, incus and stapes?

 

Ossicular chain or Auditory ossicles

 

 

 

  1. How many carpal bones form each wrist joint?

 

8 Carpal bones in each wrist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please be aware spelling will be taken into account during the marking process.

 

Section E [2] – Medical Terminology

 

Answer ALL 10 questions in this Section, writing your answers in the spaces provided.

 

 

  1. Circle the four prefixes in the list below:

 

  sub chol desis
  aden pexy trans
  hemi ec tripsy

 

 

 

  1. Describe the active or passive circular movement of a limb.

 

Circumduction

 

 

 

  1. Name the four components that make up a medical term.

 

Root word

Prefix

Suffix

Combining vowel(s)

 

 

  1. What is the meaning of the root word ‘Ost’?

 

Bone

 

 

  1. What is the root word that means joint?

 

Arthr

 

 

  1. The ending that follows a root word is known as what?

 

Suffix

 

 

  1. What does the medical term ‘Ectopic pregnancy’ denote?

 

(Gestation) outside of the uterine cavity

 

 

  1. Physiology is the study of what?

 

How the body functions

 

 

  1. ‘Anterior’ views describe which body views?

 

Views of the front of the body

 

 

  1. What is the prefix in the term ‘Abnormal’?

 

Ab

 

 

 

 

 

Section E [3] Diagrams

Precisely label the anatomical structure indicated by each line on the following two diagrams. Write your answers in the boxes below.

 

E 3 [a] Hip Joint

 

 

 

 

 

1. Pelvic bone  6. Neck of femur
2. Pubis  7. Lesser trochanter 
3. Ischium  8. Greater trochanter 
4. Ilium  9. Shaft of femur 
5. Head of Femur     

 

 

 

 

 

 

E 3 [b] Name the following muscles

 

 

 

 

Orbicularis oculi  6 Brachioradialis 
Deltoid  7 Sternocleidomastoid 
Pectoralis major  8 Trapezius 
Biceps brachii  9 Latissimus dorsi 
Rectus abdominis  10 Triceps brachii  

 

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