Question

multiple choice question

the first step in the assignment of the correct code is to look up the ______ that describes the patients condition based on the diagnostic statement.

tabular index
default code
alphabetical term
medical term

Explanation:

Identify the core coding process

The question asks for the first step in assigning an ICD-10-CM code based on a diagnostic statement. According to official ICD-10 Coding Steps, the process begins by locating the diagnostic statement in the medical record. From this statement, the coder must identify the main term.

Analyze the role of the main term

The main term is the primary medical term (such as a disease, condition, sign, symptom, or injury) that describes the patient's condition. This term is used to locate the correct entry in the Alphabetic Index.

Evaluate the given options

• tabular index: This is not a standard term (the Tabular List is used to verify codes, which is the second major step, not the first).
• default code: A default code is listed next to a main term in the Alphabetic Index, but it is not what you look up first to describe the condition.
• alphabetical term: This is not standard medical coding terminology.
• medical term: The coder must identify and look up the specific medical term (the main term) representing the condition in the Alphabetic Index.

Answer:

• tabular index
• default code
• alphabetical term
• medical term (Correct answer)