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.

default code
tabular index
alphabetical term
medical term

Explanation:

Analyze the coding process

Using the ICD-10 Coding Steps knowledge point, the first step in medical coding is to locate the diagnostic statement in the patient's medical record. From this statement, the coder identifies the main medical term (condition, disease, or symptom) to look up in the Alphabetic Index.

Identify the correct term

Using the Main Term Selection knowledge point, the coder looks up the medical term (also referred to as the main term) in the Alphabetic Index. This term represents the patient's disease, injury, or reason for the encounter, rather than anatomical sites or adjectives.

Answer:

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