question

What is ICD-10-CM?

answer

ICD-10-CM is a morbidity classification published by the U.S. for classifying diagnoses and reason for visits in all healthcare settings.

question

What are the 4 organizations that make up the Cooperating Parties for ICD-10-CM?

answer

AHA (American Hospital Association), CMS (Center for Medicare and Medicaid Services), AHIMA (American Health Information Management Association), NCHS (National Center for Health Statistics).

question

How is the ICD-10-CM organized/divided?

answer

Alphabetical Index (terms and their codes) and Tabular List (codes divided into chapters based on body system or condition).

question

What are the 4 parts of the Alphabetic Index?

answer

Index of Diseases and Injury, Index of External Causes, Table of Neoplasms, Index of Drugs and Chemicals.

question

What is the difference between Excludes1 and Excludes2?

answer

Excludes1 means do not use the code for the diagnoses listed; Excludeds2 means the diagnoses listed are not included here (in the listed).

question

What is found in the beginning of each chapter?

answer

General notes.

question

Where are Exclusion notes found?

answer

varies

question

How is ICD-10-CM codes divided?

answer

into groups of 3-digit codes

question

ICD-10-CM codes are alphanumeric with the first always a letter.

answer

True

question

Subterms are indented one standard indention in lower case letter under a main term.

answer

True

question

The fifth, sixth, or seventh characters are considered subclassifications.

answer

True

question

A carryover line is indented two standard under the main term or from the preceding line.

answer

True

question

ICD-10-CM codes always have 7 characters.

answer

False

question

Categories are 3-digit codes.

answer

True

question

More specific subterms are indented farther to the right under a subterm.

answer

True

question

Main terms are flushed left and are printed in bold type in the alphabetical index.

answer

True

question

ICD-10-CM codes uses the character "x" as a placeholder.

answer

True

question

What entity publishes the ICD-10-CM codes yearly?

answer

WHO.

question

ICD-10-CM is divided by sections which are groups of 3-character codes. T/F

answer

True

question

ICD-10-CM is published by the World Health Organization and updated yearly. T/F

answer

True

question

A dash at the end of an index entry indicates additional characters are required. T/F

answer

True

question

ICD-10-CM uses all letters of the alphabet, A-Z. T/F

answer

False

question

ICD-10-CM is used to code diagnoses and procedures. T/F

answer

False

question

Words such as "with'' "due to" and "in" express relationship between the main term or subterm indicating an associated condition or etiology. T/F

answer

True

question

ICD-10-CM will be required for all encounters on October 1, 2015. T/F

answer

True

question

ICD-10-CM has 21 chapters. T/F

answer

True

question

ICD-10-CM include codes for laterality. T/F

answer

True

question

ICD-10-CM has a Neoplasm Table, a Table of Drugs and Chemicals, and the index to External causes located at the back of the alphabetical index. T/F

answer

True

question

The alphabetical index is organized by standard alphabetical rules, such as ignoring single hyphens within words and the possessive "s". T/F

answer

True

question

Mandatory multiple coding does not have to be followed. T/F

answer

False

question

POA stands for present on admission and is used to differentiate between conditions present at admission and conditions that develop during an inpatient admission. T/F

answer

True

question

Always assign a combination code when applicable. T/F

answer

True

question

Exclusion 1 notes indicate that the code excluded should NEVER be used at the same time as the code above the Exclusion 1 note. T/F

answer

True

question

When the original treatment plan is not carried out, the admitting diagnosis is NOT used. T/F

answer

False

question

Always review the cross-reference instructions before assigning a code. T/F

answer

True

question

Exclusion 2 notes indicates that the condition excluded is part of the condition presented by the code and can not be assigned. T/F

answer

False

question

The reference to "see" must always be followed. T/F

answer

True

question

The "code first" rule requires an underlying condition to be sequenced first. T/F

answer

True

question

The principal diagnosis is established after all studies are complete. T/F

answer

True

question

NEC codes are specific and should be used as principal diagnosis. T/F

answer

False

question

With outpatient services, the primary diagnosis is the reason for the encounter. T/F

answer

True

question

The "see also" reference refers the coder to another category that may have more specific information when the entries under consideration do not meet the specific conditions or procedures. T/F

answer

True

question

NOS stands for Not Elsewhere Specified. T/F

answer

False

question

There are two types of Exclusion notes in ICD-10-CM called Exclusion 1 and Exclusion 2. T/F

answer

True

question

Parentheses enclose supplemental wording in the alphabetical index. T/F

answer

True

question

Comorbidity is defined as a preexisting condition that, because of its presence with a specific principal diagnosis, will likely increase the patient's length of stay. T/F

answer

True

question

When coding for laterality in ICD-10-CM, the digit 1 indicates the right side, and 2 indicates the left side. T/F

answer

True

question

The term "with" indicates that two elements must be present in the diagnostic statement. T/F

answer

True

question

Any existing condition which extends the length of stay or requires treatment is coded. T/F

answer

True

question

The "see condition" reference requires to coder to look elsewhere. T/F

answer

True

question

ICD-10-CM Pfficial Guidelines for Coding and Reporting are located in the code book as a reference and include chapter specific guidelines. T/F

answer

True

question

"Use additional code" means the code MUST use a second code. T/F

answer

False

question

General notes in the tabular index provides general information about the usage in a specific section. T/F

answer

True

question

A code for abnormal findings can be listed even after a specific diagnosis has been established. T/F

answer

False

question

The codes in square brackets in the alphabetical index can be used as principal diagnosis. T/F

answer

False

question

For outpatient encounters, chronic conditions that affect patient care are coded. T/F

answer

True

question

When two diagnoses equal the definition of a principal diagnosis, either can be sequenced first. T/F

answer

True

question

The current admission medication record should be reviewed. T/F

answer

True

question

The discharge summary is ALWAYS available when coding a record. T/F

answer

False

question

Codes are assigned to the highest level of specificity listed. T/F

answer

True

question

All inpatient laboratory reports should be reviewed for the current admission. T/F

answer

True

question

Physicians should be queried when the documentation does not support a listed diagnosis. T/F

answer

True

question

Match the following diagnostiec statements with the correct "condition" you would search in the alphabetical index. 1. The patient suffered a cerebral infarction of unknown origin. 2. The patient is being treated for seborrheic dermatitis of the arms. 3. The patient was seen in the ED for sutures required for a leg laceration. 4. The patient was recently diagnosed with an umbilical hernia which will require surgery. a. hernia b. infarction c. laceration d. dermatitis

answer

1. The patient suffered a cerebral infarction of unknown origin. — b. infarction 2. The patient is being treated for seborric dermatitis of the arms.— d. dermatitis 3. The patient was seen in the ED for sutures required for a leg laceration. — c. laceration 4. The patient was recently diagnosed with an umbilical hernia which will require surgery. —a. hernia

question

Physicians are aware of the reporting and coding guidelines and list diagnoses in order. T/F

answer

False

question

Physician and nursing progress notes for the current hospital admission should be reviewed prior to coding. T/F

answer

True

question

Inpatient consultations, outpatient consultations, and all other inpatient reports for the current admission should be reviewed prior to assigning diagnoses codes. T/F

answer

False

question

Review of the entire medical record is necessary for accurate coding. T/F

answer

True

question

The physician's outpatient record should be reviewed as part of the current hospital admission prior to coding. T/F

answer

False

question

The source document for coding and reporting diagnoses and procedures is the medical record. T/F

answer

True

question

The history and physical of the recent hospitalization should be reviewed. T/F

answer

True

question

You can assign a code from the alphabetical index without consulting the tabular index. T/F

answer

False

question

You can assign the three-digit code even when the code is further specified to 4, 5, or 6 digits. T/F

answer

False

question

The emergency room report from 5 days prior should be reviewed for the current hospital admission. T/F

answer

False

question

When looking up a code in the alphabetic index, the coder looks under the condition. T/F

answer

True

question

The principal diagnosis may not always be the admitting diagnosis. T/F

answer

True

question

Colons are used in inclusion and exclusion notes to connect terms. T/F

answer

True

question

Terms, such as Admission, Examination, and History are key terms to look up in the alphabetical index. T/F

answer

True

question

Match the following Z code situations to indicate whether it can be used as a principal diagnosis or assigned as an additional code. 1. Encounter for a physical exam or well baby care. 2. Encounter for a resolving disease. 3. Encounter for therapy. 4. Family history of a disease when being seen for a similar medical condition. 5. Personal history of a disease when being seen for another illness. a. additional code b. principal code

answer

1. Encounter for a physical exam or well baby care. — b. principal code 2. Encounter for a resolving disease. — b. principal code 3. Encounter for therapy. — b. principal code 4. Family history of a disease when being seen for a similar medical condition. — a. additional code 5. Personal history of a disease when being seen for another illness. — a. additional code

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