AMA 152 Chapter 3: ICD-10-CM Outpatient Coding and Reporting Guidelines Study Guide – Flashcards
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The rules of coding are represented in the Official __________ for Coding and Reporting/
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Guidelines
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If there is no clear cut outpatient guideline to follow, which type of guideline would you refer to?
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Inpatient guidelines
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It is important to code all the conditions that are being managed during an encounter.
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True
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The cause of disease or condition is also known as its _________.
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Etiology
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When two or more interrelated conditions exist, either could be the __________ diagnosis.
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First-listed
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Which codes are used when a person who is not ill receives health care services?
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Z codes
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How many chapters are located in Volume 1, Tabular list of ICD-10-CM?
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21
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When a specific diagnosis is not yet known what do you report?
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Signs and symptoms
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In an outpatient setting, _________ _________ are not reported.
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uncertain diagnosis
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Which term is now used in place of principle diagnosis?
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Primary
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The majority of the services that a physician will provide are _________ services.
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Outpatient
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UHDDS
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Uniform Hospital Discharge Data Set
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definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals.
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UHDDS
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In the outpatient setting, the term _________ ________ is used in lieu of principal diagnosis.
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First-listed diagnosis
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Most physicians will document the _______ ________ of the patient for each encounter in the medical record. The _______ ________ is the reason the patient presents for the medical visit. The ______ ________ is one of the keys to determining the first-listed diagnosis. The ________ _________ is the reason for the visit from the patient's perspective.
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chief complaint
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Code _______ is for encounters for inoculations and vaccinations; may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.
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Z23
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When a patient is to have outpatient surgery and the surgery is not performed due to contraindication, the reason that the surgery was not performed is the first listed diagnosis.
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False
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It is appropriate to code postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery.
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True
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Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions.
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True
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In the physician office it is acceptable to report Z codes as a first-listed diagnosis.
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True
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In the outpatient setting it is unacceptable to have a sign or symptom as the first-listed diagnosis.
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False
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When coding an encounter for preoperative evaluation, the reason that the patient is having the surgery or procedure performed is the first-listed diagnosis.
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False
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In the outpatient setting, diagnoses that are documented as "probable", "suspected", "rule out", or "questionable" are reported to the highest degree of certainty.
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True
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The first-listed diagnosis is defined as the diagnosis that is the most serious.
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False
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It is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80.
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False
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It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.
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False
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Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services take precedence over the general and disease specific guidelines.
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False
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Always begin the search for the correct code assignment in the Alphabetic Index.
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True
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When a patient presents for outpatient surgery and the surgery is canceled, report the reason why the surgery was canceled as the first-listed diagnosis.
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False
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The codes from A00 through Z99 are always reported as first-listed diagnoses.
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False
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When a final diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms.
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True
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External Cause codes are located in the Alphabetical Index for Diseases under External Causes.
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False
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Report all conditions that coexist, even if they are not addressed or do not affect management/treatment during that encounter.
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False
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For patients receiving diagnostic services only during an encounter/visit, sequence first the reason for the encounter/visit indicated in the medical record.
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True
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A patient with primary lung cancer with metastasis to the spine presents for radiation treatment of the spine. The first-listed diagnosis reported is the primary lung cancer.
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False
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For patients receiving preoperative evaluations, sequence first a code from the subcategory Z01.81, Encounter for preprocedural examinations, followed by findings related to the preoperative evaluation.
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False
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Routine prenatal outpatient visits for high-risk patients are reported with a first-listed diagnosis from category O09, Supervision of high-risk pregnancy.
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True
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Z codes may be reported as a principal diagnosis in the hospital setting.
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True
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Heart transplant status code Z94.1 should not be reported with a code from subcategory T86.2, Complications of heart transplant.
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True
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The External Cause codes can be reported as a first-listed diagnosis.
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False
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When a patient is admitted to observation for a complication following outpatient surgery, report the complication as the first-listed diagnosis.
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False
