Applied Coding Workbook – Flashcards

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Non essential modifiers are enclosed in: Brackets [ ] Braces Parentheses ( ) Boxes
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Parenthesis ( ) (A nonessential modifier is shown in parentheses after the term it modifies. These modifiers do not affect the code selection)
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Brackets are used in the Alphabetic Index to identify a
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Manifestation Code
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What does UHDDS stand for?
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Uniform Hospital Discharge Data Set
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Diagnoses described as "suspected", "possible", "probable", "likely", and still to be ruled out" are reported if present at the time of discharge for _________ records
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ONLY IN-PATIENT ADMISSIONS- (All non-outpatient setting such as: acute care, short term care, psych hospital, home health, rehab facilities nursing home and such.)
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Patients receiving therapeutic services in the outpatient setting for chemotherapy or radiation therapy, the first listed reported diagnostic is A. The diagnosis toward which the treatment is directed B. The appropriate Z code C. Either a or b D. The diagnosis that the physician lists first on the order
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The appropriate Z code
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When multiple burns are present, the first sequenced diagnosis is the A. Burn that is treated surgically B. Burn that is closes to the head C. Highest degree burn D. All of the above
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The burn of the highest degree (ICD-10 Chapter 19)
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A coding profession may assume a cause-and- effect relationship between hypertension and which of the following complications A. Hypertension and heart disease B. Hypertension and chronic kidney disease C. Hypertension and heart and chronic disease D. None of the above
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Hypertension and Chronic kidney disease (ICD-10 Chapter 9)
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Which letter is used as a placeholder in ICD-10 CM
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X
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New ICD-10 codes goes into effect on what date each year
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October 1
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An "excludes 1" note means
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it means "Not coded here" (ICD-10 Excludes notes)
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in ICD-10 what are brackets [ ] used for?
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They are used to enclose synonyms, alternative wording and explanatory phrases. (synonyms is a word having the same or nearly the same meaning such as happy, joyful, elated. )
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The neoplasm table includes
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The nature and status (primary, secondary, insitu) for malignancies (Neoplasm "Table" in the Alphabetic Index of ICD-10 pg. 321)
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The placeholder "x" is used as what character placeholder
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the 5th character at certain 6th character codes allow for future expansion
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the seventh character is required in length, if a code is not full sixth characters what is used as a place holder
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Place holder "X"
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Where are external cause codes for "Adverse reaction" to chemotherapy?
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They are found in the "Table of drugs and Chemicals"
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Is a "benign" neoplasm reported according to its stage?
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No, because metastasis is Not a characteristic of that behavior.
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What are the 5 categories listed in the neoplasm "Table"
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Benign, Malignant, Uncertain Behavior, and Unspecified Category. (primary, secondary or in situ status)
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What is cancer in situ mean?
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An early stage cancer in which the cancerous growth or tumor is still confined to the site from which it started, and has not spread to surrounding tissue or other organs in the body.
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What is Carcinoma in situ?
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Cancer that involves cells that line the internal organs, or epithelial cells.
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Z codes can be used as A. principle diagnosis only? B. secondary diagnosis only? C. Either principal or secondary, depending on the circumstances of admission? D. Secondary diagnosis only on "Inpatient stays and principal diagnosis on outpatient visits?
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C- Either principal or secondary, depending on the circumstances of admission. (ICD-10 Chapter 21)
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Terms listed in the "Alphabetic Index" in boldface type are known as:
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Main Terms
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Manifestation codes A. can never be reported first B. Are printed in brackets [ ] in the Alphabetic Index C. Describe a condition that results from another, underlying condition D. All of the above?
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All of the above: -Can never be reported first. -Are printed in brackets [ ] in the Alphabetic Index -Describe a condition that results from another, underlying condition
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Codes that contain the descriptive abbreviation NOS are to used
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When the coder lacks sufficient information to assign a more specific code
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What does NOS mean?
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Not Otherwise Specified- (a code is not found for a specific to allow a more granular code assignment)
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What does NEC stand for?
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Not Elsewhere Classified (when specific details of a condition are available but the classification system does not include a specific category or code.
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Meningitis due to ECHO virus
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A87.0
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Chickenpox-go to varicella
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B01.9
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Pulmonary anthrax
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A22.1
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Hereditary hemochromatosis
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E83.110
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Hypernatremia
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E87.0
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Hypercholesterolemia
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E78.0
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Hodgkin's sarcoma of thoracic lymph nodes.
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C81.92 Sarcoma/Hodgkin's/lymphoma/Hodgkins C81.9>/intra-thoracic.(2)
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What is Sarcoma
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Malignant(cancerous) tumor of connective or other nonepithelial tissue
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What is Malignant
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Cancerous cells out of control-that are spreading to other tissues and body parts.
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What is a neoplasm
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A new and abnormal growth of tissue in some part of the body.
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Malignant neoplasm of "Main" bronchus
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C34.00 Neoplasm/Table of neoplasm/bronchus.
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A Patient is admitted to hospital for radiation therapy for a primary malignancy that is still present. What code is reported as the principle diagnosis
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Z51.0 Code for the neoplasm should be assigned as principal or first listed diagnosis) -Admission/radiation therapy/antineoplastic ( If a patient admission/encounter is solely for the administration of radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy (ICD-10 Chapter 2 e.)
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Iron -deficiency anemia secondary to chronic blood loss
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D50.0 Anemia/blood loss(chronic)
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What types of diseases are found in the Alphabetic section "Syndrome"?
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Diseases named after a person
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Von Willebrands disease and hemophilia C are both types of what type of defects
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Coagulation defects
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Sickle cell trait
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D57.3 Trait/sickle cell/
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Jacob- Creutzfeldt disease with dementia
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A81.00, F02.80(secondary) Creutzfeldt-Jacob disease or syndrome with dementia Disease/ subterm Jakob-Creutzfeldt-see Creutzfeldt-Jakob disease or syndrome/Creutzfeldt Instructed to use additional code-behavioral disturbance (F02.80).
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Alcoholic dependent chronic brain syndrome
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F10.27 Alcohol/ alcoholic/ alcohol-induced /brain syndrome/chronic,/with dependence. (An additional code for blood alcohol level (Y90) may be assigned if applicable)
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Bipolar disorder currently with moderate disorder
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F31.32 Disorder/Bipolar/current/moderate
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Acute endophthalmitis
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H44.009 Endophthalmitis/acute
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Duchenne muscular dystrophy
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G71.0 Diseases/Duchenne/muscular dystrophy
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Bilateral chronic primary angle-closure glaucoma, mild stage
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H40.2231 Disease/glaucoma/angle closure primary/chronic/bilateral
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Pulmonary aneurysm
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I28.1 Aneurysm/pulmonary
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Malignant hypertension with hypertensive heart disease and congestive heart failure
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I11.0, I50.9 Hypertension, hypertensive/subterms heart, with heart failure (congestive) I11.0. Malignant is a nonessential modifier of the main term Hypertension, in the Tabular List- code I11.0 directs the use of an additional code to identify type of heart failure (I50.-?). I50.9-congestive heart failure
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Mitral valve stenosis and aortic valve insufficiency
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I08.0 ICD-10-CM provides a specific category for valve disease that involves multiple heart valves and whether they are specified as rheumatic or not. Stenosis/ mitral, with aortic valve disease; or Insufficiency, subterms aortic with mitral valve disease.
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Acute bronchitis
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J20.9 Bronchitis/acute
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Acute laryngitis with airway obstruction
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J05.0 Laryngitis/acute/obstruction
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Hypertrophy of tonsils and adnoids
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J35.3 Hypertrophy/adenoids/tonsils
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Submandibular gland abscess
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K11.3 Abscess/submandibular/gland
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Acute duodenal ulcer with bleeding
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K26.0 Ulcer/duodenal/acute/with hemorrhage
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Gastric ulcer
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K25.9 ulcer/gastric-(see ulcer, stomach)/stomach (code note unspecified chronic/acute/hemorrhage)
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Acute renal failure with lesion of tubular necrosis
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N17.0 Failure/renal/with tubular necrosis-acute
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Ureterolithiasis
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N20.1 Ureterolithiasis-see calculus, ureter
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Acute pyelonephritis
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N10 pyelonephritis/acute
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Carbuncle of the hand
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L02.539 Carbuncle/hand (code note unspecified)
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Paronychia of right finger
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L03.011 paronychia-see cellulitis, digit/finger-see cellulitis, finger/ (Code note-right finger)
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Sunburn
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L55.9 sunburn (Code note-unspecified)
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Contracted pelvis, single liveborn infant delivered vaginally
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O33.1, Z37.0 Pregnancy/complicated by (care of) (management affected by)/ contracted pelvis. (z-code)"Outcome" of delivery/single/ liveborn.
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Gestational diabetes, admitted for control not delivered
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O24.419 Diabetes/ gestational (in pregnancy). (If the patient requires insulin to manage the gestational diabetes, code O24.414 ) Note that there are different subcategory codes based upon the phase of pregnancy, O24.41- in pregnancy, O24.42- in childbirth and O24.43- in the puerperium for this condition.
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Maternal hypotension syndrome, onset 10 min after delivery 39 weeks
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O26.53, Z3A.39 Hypotension/ maternal, syndrome (following labor and delivery). The trimesters are specified in chapter 15. The third trimester is 28 weeks 0 days until delivery. The fifth character 3 specifies the third trimester. An instructional note to "use additional code from category Z3A, weeks of gestation, to identify the specific week of the pregnancy" is present at the beginning of chapter 15. Pregnancy/ weeks of gestation, 39 weeks.
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Bacterial pyogenic arthritis of left hip
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M00.852 Arthritis/pyogenic/bacterial/hip
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Rheumatoid arthritis involving the hands
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M06.9 Arthritis/rheumatoid
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Aseptic necrosis of femoral head
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M87.059 Necrosis-see osteonecrosis/osteonecrosis/idiopathic aseptic/femur (code note unspecified femur)
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Spina bifada of lumbar region with congenital hydrocephalus
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Q05.2 Spina bifada/ lumbar/hydrocephalus
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Brachial cleft cyst
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Q18.0 Cyst/branchial
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VSD
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Q21.0 VSD stands for ventricular septal defect. Defect/ septal,/ ventricular
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Anorexia
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R63.0 Anorexia/hysterical or nervosa
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Failure to thrive, 35-year old patient
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R62.7 Failure/to thrive
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Fussy infant
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R68.12 Fussy/baby
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Open skull fracture with subarachnoid and subdural hemorrhage, expired due to brain injury without regaining consciousness, initial encounter
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S02.91XB, S06.6X7A, S06.5X7A Fracture/traumatic. The specific site of the skull fracture is not stated within the diagnostic statement. The seventh character "B" is assigned to indicate the fracture is open and this is the initial encounter. Subarachnoid hemorrhage: Hemorrhage/ with intracranial/subarachnoid/traumatic. Subdural hemorrhage: The Alphabetic Index main term is Injury/intracranial/subdural hemorrhage (traumatic). For the subdural and subarachnoid hemorrhage code assignments, the sixth character "7" is selected upon review of the Tabular List to indicate the loss of consciousness with death due to brain injury, prior to regaining consciousness and the seventh character "A" is assigned to represent the initial encounte
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Traumatic fracture of C3 with complete transection of spinal cord at that level, initial encounter.
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Rationale: The Alphabetic S14.113A, S12.200A Index main term is Fracture, traumatic subterms neck, cervical vertebra, third. The seventh character "A" is used to specify a closed fracture, initial encounter. Coding Guidelines (CMS 2013a, I.C.19.c) specify that a fracture not indicated as open or closed should be coded to closed and a fracture not indicated whether displaced or not displaced should be coded to displaced. Category S12, in the Tabular List specifies to code first any associated cervical spinal cord injury (S14.0, S14.1-). The Alphabetic Index main term Injury, subterms, spinal cervical, complete lesions, C3 level. The seventh character "A" is used to represent the initial encounter.
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Traumatic fracture ribs 2 to 4 right and 2 to 5 left, initial encounter.
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S22.43XA Rationale: The Alphabetic Index main term is Fracture, traumatic with subterms ribs, multiple. The fifth character "3" is assigned to represent bilateral fractures. The seventh character "A" is used for the initial encounter for closed fracture
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A patient was injured due to a tackle in a foot ball game. The injury occurred on a football field, and the patient is a student who is on a recreational football team. assign: Cause Place of occurrence Activity Status code
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ICD-10-CM Code(s) and Rationale: W03.XXXA Index to external cause, Tackle in sport. Three placeholders are required to assign the seventh character "A" denoting the initial encounter. Y92.321 Index to external cause, Place of occurrence, football field. Y93.61 Index to external cause, Activity, football, tackle. Y99.8 Index to external cause, External cause status, specified NEC
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A patient fell from a ladder while running electrical wire inside a building construction site. Patient is an employed construction worker, initial encounter Assign: External cause Place of occurrence Activity Status code
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ICD-10-CM Code(s) and Rationale: W11.XXXA Index to external cause, Fall, falling, from, ladder. Three placeholders are required to assign the seventh character "A" denoting the initial encounter. Y92.61 Index to external cause, Place of occurrence, building under construction. Y93.H3 Index to external cause, Activity, construction. Y99.0 Index to external cause, External cause status, civilian activity done for financial or other compensation.
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Assign external cause codes for burns due to ignition of clothing from fireplace in restaurant, initial encounter. (Do not assign code of place of occurrence)
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X06.2XXA, X02.0XXA Rationale: In the Index to External Cause, the main term is Ignition, subterm apparel. There is an Excludes 2 note present at X06 indicating the exposure to a controlled fire in a building (X02) is not included in codes present in this category. An additional code is assigned to describe the exposure to the fireplace. The Index to External Cause main term is Exposure, subterm fireplace which provides the cross reference to entry Exposure, fire, controlled building. The seventh character "A" is used for the initial encounter for both code assignments.
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Encounter for artificial insemination
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Z31.83 Rationale: The Alphabetical Index main term is Encounter with subterm assisted reproductive fertility procedure cycle.
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Hepatitis B carrier
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Z22.51 Rationale: The Alphabetical Index main term is Carrier, subterm hepatitis, B surface antigen.
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History of carcinoma of the breast
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Z85.3 Rationale: The Alphabetical Index main term is History with subterm personal (of), malignant neoplasm, breast.
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