question

Code only _____ cases of HIV. Lab work is not required only the physician documents.

answer

Confirmed

question

When a patient is admitted for an HIV related condition, _____ is sequenced first followed by additional diagnoses codes for all reported HIV related conditions.

answer

B20

question

If a patient with HIV disease is admitted for an unrelated condition such as a fracture, the code for the unrelated condition is coded _______. B20 is used as an additional diagnosis.

answer

First

question

Asymptomatic human immunodeficiency virus (HIV) infection is applied when the patient is HIV positive and does not have any documented symptoms of an HIV related illness. What is the code?

answer

Z21

question

ICD-10-CM _______ ______ codes always take sequencing priority and should be listed first.

answer

Chapter 15

question

Should a patient with signs and symptoms is being seen for HIV testing, what should be coded while waiting on the results?

answer

Signs and symptoms

question

If a patient test results come back positive for HIV and the patient is symptomatic, what code should be used?

answer

B20

question

Sepsis and severe sepsis require a code to identify the ________ _________. If documentation does not include the casual organism, report A41.9 Sepsis, unspecified organism.

answer

Systematic infection

question

Severe sepsis is associated with acute organ dysfunction. A minimum of two codes are required. Code underlying condition first, followed by a code from subcategory ______ depending on what is documented.

answer

R65.2

question

Code ____ can never be used as principal diagnosis.

answer

R65.2

question

When coding septic shock, first code the systemic infection followed by R65.21 or

answer

Organ function

question

When the patient develops anemia because of the neoplasm and presents for treatment of the anemia, the code for the ________ is listed first, followed by the code for the ______.

answer

Malignancy, anemia

question

If the anemia is caused by chemotherapy or radiotherapy, the _______ code is reported first, followed by the appropriate codes for the _____________________.

answer

Anemia, neoplasm and the adverse effect

question

When coding an encounter for chemotherapy, immunotherapy, and radiotherapy, report the ___________ first, followed by the active code for the ___________________________, even if that neoplasm has already been removed.

answer

Z codes, malignant neoplasm

question

_______________ is a type of diabetes caused by something other than genetics or environmental factors. It is always caused by another condition or event.

answer

Secondary diabetes

question

_________ is the paralysis of both lower limbs.

answer

Paraplegia

question

_________ is paralysis of all four limbs.

answer

Quadriplegia

question

_________ is paralysis on one vertical half of the body.

answer

Hemiplegia

question

__________ is paralysis of one limb.

answer

Monoplegia

question

__________ is a condition when the optic nerve is damaged, causing vision loss.

answer

Glaucoma

question

________________ is any inflammation of the middle ear without reference to etiology or pathogenesis.

answer

Otitis media (OM)

question

What code should be used to report weeks of gestation?

answer

Z38

question

Should a condition originate in the perinatal period, and continue throughout the life of the patient, should the Perinatal code be used throughout the life of the patient of or should the perinatal code be discontinued after delivery.

answer

Throughout life of the patient

question

Coding of sequela generally requires two codes sequenced in the following order: _____________________________________________.

answer

the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

question

Manifestation

answer

Signs and/or symptoms of an underlying disease, not the disease itself, and therefore, cannot be a principal diagnosis.

question

Excludes 1

answer

It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. If two conditions are not related to one another, it is possible to report both codes despite the presence of an Exclude note 1. Ex: Mental disorder (F01-F99) cannot be assigned with the R40-R46 codes but if dizziness (R42) is not component if mental health condition then we can code it separately.

question

Excludes2

answer

A type 2 Excludes note represents "Not included here." An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

question

Sepsis For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.

answer

Sepsis

question

A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated __________________ is documented

answer

acute organ dysfunction

question

The term _____________ is a nonspecific term. It has no default code in the Alphabetic Index. It is not to be considered synonymous with sepsis.

answer

urosepsis

question

If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding ________________.

answer

severe sepsis

question

If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory ____________________. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code.

answer

R65.2, Severe sepsis

question

The coding of severe sepsis requires a minimum of ____ codes: first a code for the _________________, followed by a code from subcategory _________________________.

answer

2, underlying systemic infection, R65.2Severe sepsis

question

Septic shock generally refers to ______________________ associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction

answer

circulatory failure

question

If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned ____________ and the code for the localized infection should be assigned as a _____________________.

answer

first, secondary diagnosis

question

If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned _________, followed by the appropriate sepsis/severe sepsis codes.

answer

first

question

For such cases, the postprocedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded ________, followed by the code for the ______________. If the patient has severe sepsis, the appropriate code from subcategory _________ should also be assigned with the additional code(s) for any acute organ dysfunction.

answer

first, specific infection, R65.2

question

Types of MI

answer

STEMI and NSTEMI

question

The ICD-10-CM codes for type 1 acute myocardial infarction (AMI) identify the site, such as _________________________.

answer

Anterolateral wall or true posterior wall

question

Codes for type 1 STEMI are _________________________.

answer

I21.0-I21.2 and code I21.3

question

Codes for type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs

answer

I21.4

question

If a type 1 NSTEMI evolves to STEMI, assign the _______ code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as ________.

answer

STEMI, STEMI

question

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for "other diagnoses" codes from category _______ may continue to be reported.

answer

I21

question

For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate ___________ should be assigned, rather than a code from category I21.

answer

aftercare code

question

For old or healed myocardial infarctions not requiring further care, code _________, Old myocardial infarction, may be assigned.

answer

I25.2

question

Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.

answer

I21.9

question

If only type 1 STEMI or transmural MI without the site is documented, assign code ________, ST elevation (STEMI) myocardial infarction of unspecified site.

answer

I21.3

question

If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a _________________.

answer

subendocardial AMI

question

When a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI.

answer

I22 (Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction)

question

Type 1 myocardial infarctions are assigned to codes

answer

I21.0-I21.4

question

Type 2 myocardial infarction, and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code _____________________.

answer

I21.A1, Myocardial infarction type 2 with a code for the underlying cause

question

Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code ___________________.

answer

I21.A9, Other myocardial infarction type

question

1) Hypertension with Heart Disease ( I50.- or I51.4I51.9) 2) Hypertensive Chronic Kidney Disease ( I12 and type of Kidney disease N18) 3) Hypertensive Heart and Chronic Kidney Disease ( I13, Type of Kidney disease and type of heart failure) 4) Hypertensive Cerebrovascular Disease ( I60-I69) 5) Hypertensive Retinopathy 6) Hypertension, Secondary 7) Hypertension, Transient 8) Hypertension, Controlled (I10-I15) 9) Hypertension, Uncontrolled (I10-I15) 10) Hypertensive Crisis (I16) 11) Pulmonary Hypertension (I27.1, I27.2-)

answer

Hypertension coding

question

The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD). If both a stage of CKD and ESRD are documented, assign code N18.6 only.

answer

CKD Types

question

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

answer

Etiology/manifestation convention

question

Signs and symptoms that are associated routinely with a disease process _____________, unless otherwise instructed by the classification.

answer

should not be coded

question

Additional signs and symptoms that may not be associated routinely with a disease process _____________ when present.

answer

should be coded

question

If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the _________________.

answer

acute (subacute) code first

question

A combination code is a single code used to classify: ____________________________, , or _________________________, and _______________________.

answer

Two diagnoses, A diagnosis with an associated secondary process (manifestation), A diagnosis with an associated complication

question

If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______________. If the side is not identified in the medical record, assign the code for the _______________.

answer

left and right side, unspecified side

question

If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as ___________, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient).

answer

confirmed

question

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

answer

overlapping malignant lesion

question

If the treatment is directed at the malignancy, designate the malignancy as the ______________.

answer

principal diagnosis

question

When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the _____________________ even though the primary malignancy is still present.

answer

principal diagnosis

question

When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is ____________________, followed by the code(s) for the malignancy.

answer

sequenced first

question

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category _________________________________. * Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the ______________________ with the Z85 code used as a secondary code.

answer

Z codes should be given. Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. * principal or first-listed

question

If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is ________________________.

answer

sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned

question

When a patient is admitted for the purpose of insertion or implantation of radioactive elements (e.g., brachytherapy) and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is the appropriate code for the ______________________ followed by any codes for the complications.

answer

malignancy

question

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be _______________________, followed by the code for the neoplasm. *If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be ___________________,, followed by a code from M84.5 for the pathological fracture.

answer

sequenced first, sequenced first

question

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category ____________________________.

answer

Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy

question

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

answer

IMP Point Malignancy

question

If the type of diabetes mellitus is not documented in the medical record the default is E11.-, _________________.

answer

Type 2 diabetes mellitus

question

If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, _____________________. An additional code should be assigned from category ____________________ to identify the long-term (current) use of insulin or oral hypoglycemic drugs.

answer

Type 2 diabetes mellitus, should be assigned, Z79

question

If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of _____________ should be assigned.

answer

insulin

question

Code ___________ should not be assigned if insulin is given temporarily to bring a type 2 patient's blood sugar under control during an encounter.

answer

Z79.4

question

An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory _________________________.,

answer

Mechanical complication of other specified internal and external prosthetic devices, implants and grafts

question

The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be ___________________________ followed by code ___________________________.

answer

* T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts. * T38.3X1, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional). 6

question

Codes under categories E08, Diabetes mellitus due to underlying condition, E09, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).

answer

Secondary diabetes mellitus

question

For patients with secondary diabetes mellitus who routinely use insulin or oral hypoglycemic drugs, an additional code from category _______________ should be assigned to identify the long-term (current) use of insulin or oral hypoglycemic drugs.

answer

Z79

question

If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code ____________ should not be assigned if insulin is given temporarily to bring a secondary diabetic patient's blood sugar under control during an encounter.

answer

Z79.4

question

Good

answer

Good

question

Review definition of 5th digits in category; Understand the difference between type 1 ; 2 and the patho of each type.

answer

When assigning Diabetes Diagnosis remember what 2 things?

question

Specific type of Pneu Know criteria for recognizing gram negative and other types of pneu; review the various types of COPD and how ACUTE exacerbation of each is coded. (AHA coding Clinic); Review criteria for coding respiratory failure and when it is sequenced.

answer

When coding Respiratory what things should you look for?

question

Do not code it unless there is documention that the excis debridement was performed. Check AHA CC.

answer

How do you code an excisional debridement?

question

Use a combination code whenever available that incorporates a hemorrhage and the specific disorder. Use the 578.x category as an additional code when no combo code has been created or when the cause of the hemorrhage is unknown.

answer

When a dx of Gastrointestinal is aparent, what rule should you follow?

question

The 5th digit of 4

answer

Delivery and Pregnancy Dx - what digit is only used for a postpartum complication?

question

Code 650; Delivery is entirely normal w/single liveborn outcome; No postpartum complications, and any antepartum comp experienced during pregnancy must have been resolved before the time of delivery.

answer

What is the definition of a Normal Delivery?

question

Delivery Dx code (6xx) Outcome of Delivery (V2x.xx) Px code (73.59 if not other px was performed)

answer

What 3 codes do delivery patients always have to have?

question

Spontaneous (634)

answer

This type of Abortion occurs wo any instrument or chemical intervention.

question

Legally induced (635)

answer

This type of Abortion performed for either therapeutic or elective termination of pregnancy (elective abortion, induced, artificial, termination of pregnancy)

question

Illegally Induced (636)

answer

This type of Abortion is not performed in a accordance w/provisions of state law or not meeting regulartory requirements . Performed outside of the hospital.

question

Failed (638)

answer

This type of Abortion is one in which an elective abortion px has failed to evacuate or expel the fetus and the patient is sitll pregnant.

question

To indicate whether the abortion is complete or incomplete.

answer

What is the 5th digit sub classification used for when coding an abortion?

question

V codes; ex: V64.41 ( Laparoscopic surgical procedure converted to open procedure )

answer

If a patient goes in for surgery and planned having a laparoscopic px but has to an open px, what type of code would you assign?

question

Code to N18.6 (ESRD) and dialysis status Z99.2

answer

Chronic kidney disease stage 5

question

Underlying infection + R65.2

answer

Severe sepsis

question

Underlying infection + R65.1

answer

Septic shock

question

Additional code of Y95

answer

Nosocomial infections

question

Code only confirmed cases (diagnosis sufficient)

answer

HIV infections

question

Admitted for HIV- B20 A/D unrelated- unrelated first then B20 Asymptomatic HIV- Z21 Inconclusive HIV- R75 Previously diagnosed- B20 HIV in pregnancy- O98.7 Asymptomatic HIV in pregnancy- O98.7 + Z21 Encounters for testing of HIV- Z11.4 Return visit for negative test results- Z71.7

answer

Sequencing HIV codes

question

Has a unique category

answer

Labor pneumonia

question

Coded to the lower anatomic location

answer

Respiratory condition occurring in more than one place

question

Code exposure to tobacco

answer

Respiratory condition

question

Means ulcers

answer

Gastrointestinal term hemmorrhage

question

Means gastritis, duodenitis, diverticulosis, diverticulitis

answer

Gastrointestinal term bleeding

question

5th or 6th digit represents trimester

answer

Delivery and pregnancy

question

1- less than 14 wks 2- less than 28 wks, more than 14 3- 28 wks thru delivery

answer

Trimesters

question

a) Delivery diagnosis code b) Outcome of delivery c)Weeks of gestation d) Procedure code

answer

Delivery chart codes should include

question

O80

answer

Normal delivery code

question

Z3A

answer

Weeks of gestation code

question

Require additional codes

answer

Complications of ectopic pregnancy and abortions

question

Code also the cause Code first the poisoning and under-dosing of medications If associated with malignancy, code malignancy first

answer

Anemia

question

Code as a subenocardial MI

answer

MI documented as nontransmural or subendocardial with a site provided

question

Code from I22 and I21

answer

Subsequent MI within 4 weeks of initial

question

Is where the cancer arises

answer

Primary site of neoplasm

question

When cancer leaves the original site

answer

Secondary neoplasm

question

For example: renal cell carcinoma arises in the kidney

answer

Morphology can lead to primary site

question

1. Look up morphology 2. No primary site code- use neoplasm table 3. If the term metastatic is used assume these are secondary sites: Bones, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, spinal cord, and sites from C76

answer

Steps for coding neoplasms

question

Use code from ch. 20 to indicate cause of injury

answer

Injuries and burns

question

Use only the degree of greatest severity along with the additional codes for burns of other anatomic sites

answer

Burns on different body parts

question

Allergic reaction Cumulative effect Hypersensitivity Idiosyncratic reaction Paradoxical reaction Synergistic

answer

Adverse effect of a drug

question

Administered, taken or prescribed incorrectly Alcohol in conjunction with a drug Street drugs resulting in overdose Street drugs in addition to OTC or prescription meds. Two OTC drugs used together

answer

Poisoning

question

a) Present at the time the order for inpatient admission occurs b) Develop during outpatient encounter (emergency, observation, surgery)

answer

POA

question

Y= present at time of inpatient admission N= not present at the time of admission U= documentation is insufficient to determine if condition is present on admission W= provider is unable to clinically determine whether condition was present on admission or not

answer

POA Definitions

question

To locate the appropriate table that contains all information necessary to construct a procedure code

answer

Alphabetic Index PCS

question

When used in a code description means and/or

answer

And

question

Specifies body parts above or below the diaphragm respectively

answer

Upper and lower body parts

question

a) if the same root operation is performed on different body parts b) the same root operation is repeated at different body sites that are included in the same body part value c) multiple root operations with distinct objectives are performed on the same body part d) the intended root operation is attempted using one approach, but is converted to a different approach.

answer

Multiple procedures during the same operative episode

question

Code the procedure to the root operation performed

answer

Intended procedure discontinued

question

Code the root operation inspection of the body part or anatomical region inspected

answer

Procedure discontinued before root operation is performed

question

Coded using; excision, extraction, or drainage + the qualifier diagnostic (qualifier diagnostic is used only for biopsies)

answer

Biopsy procedure

question

Both are coded

answer

Biopsy + more definitive procedures

question

The body part with the deepest layer is coded

answer

Overlapping layers

question

The body part bypassed from and to. The fourth character is the from and the qualifier is the to

answer

Bypass procedures

question

Classified by number of distinct sites treated

answer

Coronary arteries

question

A separate procedure is coded for each coronary artery site that uses a different device and/or qualifier

answer

Multiple coronary artery sites bypassed

question

Stopping or attempt to stop post-procedural bleeding; if unsuccessful and another more definitive root operation is performed code that instead of control

answer

Root operation Control

question

All of a specific body part is cut out or off

answer

Resection

question

Cutting out of a less specific body part

answer

Excision

question

A separate procedure is coded

answer

Autograph obtained from a different body part

question

Classified by the level of the spine

answer

Fusion of spine

question

Separate procedure is coded for each vertebral joint that uses a different device and/or qualifier

answer

Multiple vertebral joints fused

question

Coded with the device value inter-body device

answer

Interbody fusion

question

Device value no autologous tissue substitute or autologous tissue substitute

answer

Bone graft

question

Code with device value autologous tissue subsitute

answer

Mixture of autologous and non autologous bone graft

question

Not coded separately if used to achieve the objective of the procedure

answer

Inspection

question

Code the most distal part inspected

answer

Multiple tubular parts inspected

question

Body part that specifies the entire area inspected is coded

answer

Multiple non-tubular parts inspected in a region

question

If using a different approach the inspection is coded seperately

answer

Inspection and another procedure performed at the same time

question

Embolization to completely close a vessel

answer

Occlusion

question

Embolization to narrow the lumen of a vessel

answer

Restriction

question

Body part being freed is coded not the tissue being manipulated

answer

Release procedure

question

Freeing a body part without cutting

answer

Relaease

question

Separating or transecting a body part

answer

Division

question

a) Of displaced fracture; coded to the root operation b) reposition and the application of a cast or splint; reposition is not coded separately c) non displaced fracture is coded to the root operation immobilization in the placement section

answer

Reduction

question

a) Putting in a mature and functioning living body part taken from another individual or animal b) putting in autologous or non-autologous cells is coded to the administration section

answer

Transplantation

question

Retrovir, AZT, Videx

answer

AIDS

question

Claritin, Phenergan, Allegra, Zyrtec, Benadryl

answer

Allergies

question

Feosol, Feriron, Fergom, Procrut, Epigen, Neupogen

answer

Anemia

question

Verpamil, diltiazem, nifedipine

answer

Angina pectoris

question

Ativan, Xanax, Valium, lorazepam, diazepam

answer

Anxiety

question

Verapamil, digoxin Lanoxin, quinidine,

answer

Arrhythmia

question

Ibuprofen, Lodine, naproxen, prednisone, Deltasone, Relafen

answer

Arthritis

question

Note is found at the etiology code or underlying condition

answer

Use additional code

question

Note is found at the manifestation code to provide instruction that the underlying condition should sequenced first

answer

Code first

question

Indicate two code may be require

answer

Code also

question

Usually have the phrase in disease classified elsewhere never use as first listed or principal diagnosis

answer

Manifestation code

question

Instruction for See" is mandatory you cannot code without following

answer

See"

question

Note means not code here two condition cannot occur together

answer

Excludes1

question

Not include here but patient may have both condition

answer

Exclude2

question

Under the main anomaly

answer

Congenital condition

question

Are found under delivery, pregnancy, puerperal

answer

Condition that complicate pregnancy, childbirth

question

Are found under complication

answer

Complication of medical or surgical

question

Found under Sequelae

answer

Late effect

question

21 chapterwaa

answer

Chapter

question

Are closed classification provide one and only one place to classify condition and procedure

answer

ICD-10-CM/PCS

question

Are often grouped together in residual code labeled not elsewhere classified

answer

Condition that occur infrequently or low importance

question

Published by American Hospital Association

answer

AHA coding clonics

question

Seen place holder X

answer

Chapter 19

question

Identify disease condition or injuries

answer

Main term

question

Indicate site, type, or etiology

answer

Subterms

question

Are used to enclosed supplementary words or explanatory information that may either present or absent without affecting the code (non essential

answer

Parentheses

question

To enclosed synonyms , alternative wording, abbreviation and explanatory that provide additional information or can also be used to indicate that the number in the bracket can only be a manifestation

answer

Square brackets

question

Are used in the tabular list in both inclusion note and exclusion note after an incomplete

answer

Colon

question

Interpret as either and or Or

answer

And

question

Mean as associate with or due to

answer

With

question

Casual relationship between condition is present

answer

Due to

question

The symptom code is code first

answer

Symptoms followed by contrasting / comparative diagnoses

question

Are systemic disease that are ordinarily should be coded even in the absence of documented intervention

answer

Chronic condition such as hypertension, Parkinson's disease, chronic obstructive pulmonary disease, diabetes mellitus

question

Is not an element of the UHDDS (uniform hospital discharge data set

answer

Admitting diagnosis

question

Does not apply to the coding of outpatient

answer

Uniform hospital discharge data set

question

Usually recorded on the face sheet, final progress sheet or discharge summary

answer

Discharge diagnoses

question

As long as there is no conflict information between from the information from the attending if conflict queried the the attending physician

answer

It is appropriate to base Code assignment on the documentation of other physician

question

Encounter, admission , examination

answer

Z code section

question

Indicate that a diagnosis is still possible code as confirmed

answer

Rule out

question

Indicates that a diagnosis once considered likely is no longer possible never code

answer

Ruled out

question

Two code that provide info about both a manifestation and the associate underlying condition the first code identifies the underlying condition and the second identifies the manifestation

answer

Dual coding

question

Code left and right No side identified assign the code for unspecified

answer

No bilateral

question

Condition should be code as established diagnosis

answer

Possible, probable, suspected, likely, questionable or rule out

question

As if they were established

answer

Do not Code unconfirmed condition such as HIV, multiple sclerosis, epilepsy

question

Should code only as confirm unless the classification provide a specific index entry

answer

Borderline condition

question

No entry in the index code the presenting condition if there is an entry code it

answer

Threatened / impending

question

May occur at any time require two code, condition or nature of late effect or late effect code (second second)

answer

Sequelae or late effect

question

Factor influencing Heath status and contact (Z codes: Z00-Z99)

answer

Z code

question

V00-Y99

answer

External codes

question

Some can be used as principal or fist listed diagnosis

answer

Z codes

question

Are assigned as additional code

answer

External codes

question

Admission, examination, history, observation, aftercare, problem, status

answer

Locate z code & external

question

Used T36-T65

answer

External code are not used to report the intent for poisoning toxic effect adverse effect underdosing of drug

question

For specific after care such as removal of internal fixation, sole purpose of special therapy radiotherapy chemotherapy

answer

Z codes are used as principal

question

Z42-Z51

answer

After care visit

question

Should not be used for aftercare injuries

answer

After care code

question

Admission. Examination history observation aftercare problem status

answer

Locating Z codes and external cause

question

Can be designated followed by two or more contrasting comparative condition

answer

Chapter 18

question

Is assigned principal diagnosis when the reason is admitted for the purpose of surveillance after the initial treatment has been completed

answer

Z08,Z09, Z39

question

Encountered for medical observation for suspected disease and condition ruled out

answer

Z03

question

Encountered for examination and observation for other disease and c

answer

Z04

question

Only as principal not secondary

answer

Z04, Z03

question

Only for encounter for rape if no physical finding if physical finding is found do not assigned Z04.41

answer

Z04.41 cover collection of specimen advice given & counseling

question

Refers to an earlier surgery injury illness no significance for the episode of care no code for the condition is assogn

answer

A diagnostic expressed status post

question

Are assigned for long termed of a condition not to treat acute illness or brief period

answer

Z79

question

Chapter 18

answer

Sign and symptom

question

Assessing the degree of consciousness 3 factors amout of eye opening, verbal responsiveness motor responsiveness

answer

Glasgow coma scale

question

R99 patient who has already died is brought into an emergeny

answer

Ill-defined condition

question

Presence of bacteria in the bloodstream after a trauma or an infection

answer

Bacteremia

question

SIRS due to infection a severe case indicates organ dysfunction

answer

Sepsis

question

Circulatory failure associated with severe sepsis

answer

Septic shock

question

Systemic disease associate with pathological microorganism or toxins in the bloodstream

answer

Septicemia

question

Systemic inflammatory response syndrome a systemic response to infection or trauma with such symptoms as fever and tachycardia

answer

SIRS

question

Infection and parasites disease and Take precedence over other chapter for the same condition

answer

Chapter 1

question

The index provides Subterms for both but the Subterms for the organism takes precedence over the Subterms chronic

answer

For a chronic cystitis due to gonococcus

question

Go to infection

answer

If the organic is specified but not indexed under main term

question

Respiratory illness caused by a corona virus begin with fever may include chills headache malaise Z20.828,B97.21, J12.81

answer

Severe acuterespiratory syndrome (SARS)

question

Bite of mosquitos fever, headache, body ache elderly patient or those weakened immune system the virus may cause encephalitis meningitis or permanent neurological damage A92.3

answer

West Nile virus fever

question

Caused by Mycobacterium tuberculosis and mycobacterium bovis spread through the air A15-A19

answer

Tuberculosis

question

Can never be assigned principal diagnosis

answer

R65.2

question

Coding require a minimum of two code underlying infection first followed by a code from subcategory R65.2 severe sepsis additional code for the organisms should be code

answer

Severe sepsis

question

Code first underlying condition follow by localized followed by localized infection,

answer

Sepsis and severe sepsis with a localized on admission

question

Code first localized infection follow if severe sepsis develop after admission code it second

answer

Sepsis and severe sepsis with a localized not present on admission

question

Caused by bacteria infection, symptoms include high fever vomiting watery diarrhea myalgia hypotension

answer

Toxic shock syndrome

question

MedicAl treatment develop during hospitALIZation

answer

Nosocomial infection

question

For all positive diagnosis HIV positive Or HIV related is sufficient

answer

B20

question

Without further provider should be assign a code R73.0 abnormal glucose

answer

Borderline diabetes

question

To a group of serious life threatening metabolic, can occur after antineoplastic therapy leukemia and lymphomas when cancer cell is destroy they can release intra cellular ions and metabolic into the circulation

answer

Tumor lysis syndrome

question

Is code to F01-F09

answer

Mental disorders

question

Assign code for abuse

answer

If use and abuse

question

Assign only code for dependence

answer

Abuse and dependence

question

Assign code for dependence

answer

Use, dependence, abuse

question

Assign code for dependence

answer

Use, dependence

question

Code first the underlying condition follow by anemia code

answer

Anemia

question

Code first underlying condition

answer

F01-F09

question

Failure of the bone marrow to produce red blood cell maybe congenital but usually idiopathic or acquired

answer

Aplastic anemia

question

The disease is passed to a child when both parents carry the genetic trait

answer

Sickle cell anemia or disease

question

The disease is passed to a child when one parent carry the genetic trait

answer

Sickle cell trait

question

Do not generally develop sickle cell disease they carry the trait

answer

Sickle cell trait

question

Assign only sickle cell disease

answer

Medical record both sickle cell disease and sickle cell trait

question

May occur following surgery but not necessarily a complication of the procedure and should not be coded as a postoperative complication unless the physician identifies it as such

answer

Acute blood loss anemia

question

Code first the underlying kidney disease N18 follow by anemia code D63.1

answer

Anemia chronic kidney disease

question

Code the neoplasm C00-D49

answer

Anemia in neoplastic

question

Code first the underlying chronic disease

answer

Anemia of other chronic disease

question

Anemia code sequence first follow by the adverse effect

answer

Anemia with adverse effect of chemotherapy and the trea men is for anemia

question

Caused by failure of the bone marrow to produce red blood cells

answer

Aplastic anemia

question

Type of aplastic anemia that represent a deficiency of all three elements of the blood

answer

Pancytopenia

question

Paralysis of one side of the body. What side is dominant or nondominant. For ambidextrous patient default should be dominant, left side is affected non dominant, right side dominant

answer

Hemiplegia/hemiparesis

question

Often clear quickly code from categoryG81 event without treatment

answer

If hemiplegia occurring with cerebrovascular accident(CVA)

question

Maybe used in conjunction with pain other pain code maybe used as principal diagnosis

answer

Pain in category G89

question

If the pain is specified as acute chronic post thoracotomy postpocedural or neoplasm related or the underlying diagnosis is known

answer

Do not assign code G89

question

Only confirm diagnosis do not code if stat men indicate suspected possible likely

answer

Code influenza to category J09

question

Acute life threatening upper respiratory infection

answer

Supraglottitis

question

Alveoli are deflated

answer

Atelectasis

question

Accumulation of fluid within the pleural may principal diagnosis if treatment is for pleural effusion

answer

Pleural effision

question

Excision

answer

Biopsies to the root

question

Using extreme heat freezing chemical (cryoablation) microwaves radiofrequency under the root destruction

answer

Ablation

question

Classifies to the extracorporeal assistant and performance

answer

Mechanical ventilation non invasive

question

Performance

answer

Invasive mechanical ventilation

question

Root operation extirpation

answer

Removal of biliary ducts

question

Destroy biliary stones root fragmentation approach external

answer

Extracorporeal shock wave lithotripsy

question

To the root release should not be coded unless is required before operation

answer

Adhesion of lysis

question

Classified as a ventral hernia

answer

Incisional hernia

question

Classified as obstructed

answer

Incarcerated or strsngulated

question

Classified to hernia with gangrene

answer

Hernia with both grangrene and obstruction

question

If using per cutaneous approach it is coded as bypass

answer

Peritoneal

question

Is coded to extracorporeal assistance and performance

answer

Hemodialysis

question

Require two code one for insertion and another one for insertion of reservoir

answer

Implantable venous access device

question

Tubular graft used to connect the artery and vein( creation of arteriovenous graft root operation is bypass

answer

Arteriovenous graft

question

Via natural or artificial opening endoscopic

answer

Cystoscopic approach

question

Approach is via natural or artificial opening

answer

Procedure describe as transurethral

question

Is code to via natural or artificial opening endoscopic

answer

Transurethral endoscopic

question

Is coded to the root operation extirpation

answer

Lithotripsy with removal of fragments

question

Is coded to the root operation extirpation

answer

Per cutaneous nephrostomy

question

Two code one for the removal uterus and for cervix

answer

A total hysterectomy remove the whole uterus and cervix

question

Is code to destruction

answer

Endometrial ablation

question

Root operation drainage (fluid removal)or excision (removal of a mass or lump) Seventh character X for diagnostic

answer

Biopsies of breast

question

It is customary to perform a biopsy first before the definitive surgery. Definitive surgery is sequence first follow by biopsie

answer

Surgery of breast is performed for neoplasm

question

Code first underlying condition (gangrene etc)

answer

Ulcer

question

Condition is due to poisoning (T36-T65) is sequence first if for adverse effect (T36-T65) sequence second

answer

T36-T65

question

Treatment to the cellulitis is code first treatment to the open wound open wound is code first

answer

Cellulitis

question

Always code first if present

answer

Grangrene code

question

Code infection following procedure T81.4

answer

If a person is read mitt because

question

To the root excision

answer

Excisional debridements

question

To the extraction or to the root irrigation when perform by irrigating

answer

Non-excisional debridements

question

Versajet and ultrasonic debridements

answer

Example of nonexcisional debridements

question

Layer of excision

answer

Code only the deepest

question

Bones that are weakened by disease

answer

Pathological fracture

question

Are always pathological

answer

Spontaneous fracture

question

Treatment to fracture first treatment to neoplasm neoplasm first

answer

Fracture sequence

question

Fracture together

answer

Never code traumatic and pathological

question

Require two codes one for root operation reposition and another for root supplement same for arcuplasty, kyphoplasty, skyphoplasty, spineoplasty

answer

Coding for percutaneous vertebroasty or percutaneous vertebral augmentation

question

One code supplement root code

answer

Vertebroasty

question

With chapter 15

answer

Do not use Z34

question

Z34 no code from chapter 15

answer

Normal routine pregnancy

question

O09

answer

High risk patient prenatal

question

Always first diagnosis no complication can be present

answer

O80

question

Via natural or artificial opening endoscopic

answer

Cystoscopic approach

question

Approach is via natural or artificial opening

answer

Procedure describe as transurethral

question

Is code to via natural or artificial opening endoscopic

answer

Transurethral endoscopic

question

Is coded to the root operation extirpation

answer

Lithotripsy with removal of fragments

question

Is coded to the root operation extirpation

answer

Per cutaneous nephrostomy

question

Two code one for the removal uterus and for cervix

answer

A total hysterectomy remove the whole uterus and cervix

question

Is code to destruction

answer

Endometrial ablation

question

Root operation drainage (fluid removal)or excision (removal of a mass or lump) Seventh character X for diagnostic

answer

Biopsies of breast

question

It is customary to perform a biopsy first before the definitive surgery. Definitive surgery is sequence first follow by biopsie

answer

Surgery of breast is performed for neoplasm

question

Code first underlying condition (gangrene etc)

answer

Ulcer

question

Condition is due to poisoning (T36-T65) is sequence first if for adverse effect (T36-T65) sequence second

answer

T36-T65

question

Treatment to the cellulitis is code first treatment to the open wound open wound is code first

answer

Cellulitis

question

Always code first if present

answer

Grangrene code

question

Code infection following procedure T81.4

answer

If a person is read mitt because

question

To the root excision

answer

Excisional debridements

question

To the extraction or to the root irrigation when perform by irrigating

answer

Non-excisional debridements

question

Versajet and ultrasonic debridements

answer

Example of nonexcisional debridements

question

Layer of excision

answer

Code only the deepest

question

Bones that are weakened by disease

answer

Pathological fracture

question

Are always pathological

answer

Spontaneous fracture

question

Treatment to fracture first treatment to neoplasm neoplasm first

answer

Fracture sequence

question

Fracture together

answer

Never code traumatic and pathological

question

Require two codes one for root operation reposition and another for root supplement same for arcuplasty, kyphoplasty, skyphoplasty, spineoplasty

answer

Coding for percutaneous vertebroasty or percutaneous vertebral augmentation

question

One code supplement root code

answer

Vertebroasty

question

With chapter 15

answer

Do not use Z34

question

Z34 no code from chapter 15

answer

Normal routine pregnancy

question

O09

answer

High risk patient prenatal

question

Always first diagnosis no complication can be present

answer

O80

question

Extraction root operation

answer

Cesarean deliver

question

Extraction

answer

Vaginal delivery assistance with forceps vacuum internal version

question

initial encounter for fracture

answer

A

question

subsequent encounter for fracture with routine healing

answer

D

question

subsequent encounter for fracture with delayed healing

answer

G

question

sequela of fracture

answer

S

question

Not elsewhere classifiable - ICD-10-CM system does not provide a code specific for patient's condition

answer

NEC

question

Not elsewhere specified - equivalent to "unspecified"

answer

NOS

question

Brackets are used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Brackets are used in the Index of Diseases and Injuries to identify manifestation codes in which multiple coding and sequencing rules will apply

answer

[ ]

question

Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure. They do not affect the code (nonessential modifiers)

answer

( )

question

Colon is used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category

answer

:

question

are used when the information in the medical record provides detail for which a specific code does not exist

answer

Other

question

are used when the information in the medical record is not available for coding more specifically

answer

Unspecified

question

"Not coded here" This note indicates that the code should not be used at the same time as the code above (two conditions that cannot occur together)

answer

EXCLUDES1

question

"Not included here" This note indicates that the condition excluded is not part of the condition represented by the code (patient may have both conditions at the same time)

answer

EXCLUDES2

question

This note appears directly under a there-character code title to define further

answer

INCLUDES

question

An additional code should be used after a primary code to provide a more complete picture of the diagnosis

answer

Use additional code

question

This note indicates two codes are needed to report a condition and requires that the underlying disease (etiology) be coded first, and the manifestation be coded second

answer

Code first

question

This code may be assigned as a diagnosis when the causal condition is unknown or not applicable

answer

Use additional code, if applicable

question

NEC

answer

Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists? Refer to ICD-10-CM guidelines, section I.A.6.

question

D70.4, R50.81

answer

Cyclic neutropenia is coded with D70.0 Cyclic neurtopenia. There are additional coding instructions for this code listed under the category D70 Neutropenia. Using those instructions, how would you report a patient with cyclic neutropenia with an associated fever?

question

They do not affect code assignment

answer

Supplementary words enclosed in parentheses in the ICD-10-CM codebook have what effect on the coding? Refer to ICD-10-CM guidelines, section I.A.7.

question

The code that represents the condition most commonly associated with the main term

answer

What is a default code? Refer to ICD-10-CM guidelines, section 1.A.18.

question

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