Diagnosis Coding Module 2 – Flashcards
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ICD-10-CM Guidelines HIV infection -Code only _________ cases, rules for sequencing Infectious agents as the cause of diseases classified to other chapters -Use of categories B95, B96, and B97 Infections resistant to _________ -Use of category Z16 Sepsis, severe sepsis, and septic shock and sequencing
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confirmed antibiotics
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Combination Codes and Multiple Coding Combination codes identify both the condition and the causative organism Mandatory multiple coding is required to describe etiology and manifestation when infectious and parasitic diseases produce a manifestation within _______ body system Alphabetic Index identifies two code
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another
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Sepsis, Severe Sepsis and Septic Shock in ICD-10-CM Review definition of "sepsis" Serious medical condition caused by the body's immune response to an infection Coder must review the physician's documentation to determine if the causative organism is known If _____ the term sepsis is documented, code A41.9, Sepsis, unspecified is the appropriate code
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only
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Sepsis, Severe Sepsis and Septic Shock in ICD-10-CM Review definition of "severe sepsis" An infection associated acute organ dysfunction May also be referred to as systemic inflammatory response syndrome due to an infectious process with acute organ dysfunction _____ codes are required to code severe sepsis
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Two
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Sepsis, Severe Sepsis and Septic Shock in ICD-10-CM Review what is meant by septic shock If septic shock is present, additional ______ are required to identify the specific acute organ dysfunction, such as acute kidney failure (N17.-) or acute respiratory failure (J96.0-) The Tabular List states that code R65.20 and R65.21 for severe sepsis without or with septic shock cannot be used as the _________, first-listed or the only code. A "code first underlying infection" note appears to state to code first the particular __________ that produced the severe sepsis.
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codes principal infection
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HIV Disease in ICD-10-CM Review the facts about HIV infection and AIDS The HIV classification includes categories and codes: ____ Human immunodeficiency virus [HIV] disease ____ Asymptomatic human immunodeficiency virus [HIV] infection status ____ Inconclusive laboratory evidence of HIV
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B20, Z21, R75
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HIV Disease in ICD-10-CM Follow the coding guidelines for HIV disease Only confirmed cases of HIV disease are coded AIDS code B20, followed by additional codes for _____ reported HIV-related conditions Coding of pregnancy and HIV disease uses a code from the _________ chapter
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all pregnancy
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HIV Disease in ICD-10-CM Patient with HIV disease but treated for an unrelated condition, such as a traumatic injury or a disease not caused by HIV disease. Code B20 for HIV is the _________ diagnosis Asymptomatic HIV infection status code _____ Patients with inconclusive laboratory evidence of HIV code ____
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additional Z21 R75
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HIV Disease in ICD-10-CM Testing for HIV Z22.1, Encounter for screening for HIV Additional ______ may be applicable for high risk sexual behavior and for HIV counseling when provided during the screening encounter -Positive test results -Asymptomatic patient Z21 -Symptomatic patient—code to the disease ________
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codes present
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Sequelae of Infectious and Parasitic Diseases in ICD-10-CM (B90-B94) Certain infectious and parasitic diseases leave long-lasting effects after the infection is cured, which may be called a ________ condition Categories B90-B94 are used to identify the _________ infection that produces the problem or condition that patient has as a result of the infection. Categories B90-B94 are not used if the original condition is still _________ or if the condition is identified as a chronic infection. See "code first" note to code the condition the patient today first with an additional code to identify the sequelae fact
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residual original present
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Bacterial and Viral Infectious Agents B95-B97 Codes are identified in the Alphabetic Index under "_________" or the name of the organism, such as "Streptoccoccus" Codes from B95-B97 will most likely be used with another code that identifies the ______ of an infection but does not include the causative organism For example, the diagnosis of urinary tract infection due to E. coli would require two codes N39.0 Urinary tract infection, site not specified B96.20 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere
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infection site
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Infection with Drug Resistant Microorganisms Coding of bacterial infections that are resistant to current antibiotics This specificity is necessary to identify all infections documented as antibiotic resistant Code ____, Infections with drug resistant microorganisms, is assigned following the infection code for such cases
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Z16
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Methicillin Resistant Staphylococus Aureus (MRSA) Coding of conditions due to MRSA bacteria are coded in one of two ways -A ___________ code that identifies the infection is due to MRSA -An __________ code to identify the MRSA as the causative organism (B95.62) with a code for the site of the infection Alphabetic Index entries main term of "infection" Compare MRSA and MSSA—Methicillin susceptible Staphylococus aureus (B95.61)
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combination additional
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ICD-10-CM Guidelines for Chapter 2, Neoplasms ICD-10-CM Guidelines for Neoplasm include general neoplasm guidelines Reference the _________ Table first If histological term is documented, that term may be referenced in _________Index first
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Neoplasm Alphabetic
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ICD-10-CM Neoplasm Table Organized into seven columns First or Left column = Anatomic site for the neoplasm Next 6 columns codes for -_________ malignant -_________ malignant -_________ (CA) in situ -________ -________ -________
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primary, secondary, carcinoma, benign, uncertain, unspecified
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ICD-10-CM Neoplasm Table Topography ICD-10-CM classifies neoplasms by topography Topography is a description of a ________ or a specific part of the body
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region
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ICD-10-CM Neoplasm Table Histology ICD-10-CM Neoplasm Table does not include neoplasms by histology Histology is the study of the cell __________ under the microscope Certain neoplasms are identified by the histologic name of the cell structures, for example, oat cell carcinoma of the lung
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structures
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ICD-10-CM Neoplasm Table Histology For certain neoplasm such as for malignant melanoma and certain neuroendocrine tumors, the histology is _________ in the category and codes
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included
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ICD-10-CM Neoplasm Table Morphology Morphology is the term used to describe the neoplasm in its ______ and _________ but is not included in the neoplasm table The description of the neoplasm will usually indicate which of the _____ columns is appropriate for coding, such as basal cell carcinoma or benign fibroadenoma
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form structure six
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ICD-10-CM Neoplasm Table When the name of the neoplasm does not readily identify the behavior of the neoplasm as malignant or benign, the coder should use the remainder of the ________ to identify which column to use on the Neoplasm Table to assign the code. For example: Giant cell glioblastoma of brain Is that a malignant or benign condition? Coder should use the Alphabetic Index and locate the term "Glioblastoma" Glioblastoma, giant cell, specified site (brain)—see Neoplasm, malignant, by site (brain) Next step is to use the __________ table under the anatomic site, brain, malignant, primary, and use the code for that entry
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Index Neoplasm
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ICD-10-CM Neoplasm Table Laterality is included in ICD-10-CM for neoplasms Codes listed in the Neoplasm Table with a _______ (-) following the code have a required fifth character for laterality, that is, right or left side The _________ List must be reviewed for the complete code
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dash Tabular
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ICD-10-CM Chapter 2 Index Instructions for Classifying Neoplasms If the morphology is stated, the coder must locate the morphology of the tumor in the Index to Diseases and Injuries. For example, entries exist of lipoma, melanoma, sarcoma and specific codes for these types of neoplasms are included in the Index and the coder does not need to reference the ___________ at all
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Neoplasm
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ICD-10-CM Chapter 2 Index Instructions for Classifying Neoplasms If the morphology is stated, the coder must locate the morphology of the tumor in the Index to Diseases and Injuries. However, not every entry in the _______ will include codes. For example, if the doctor writes "subependymal glioma of the brain," the Index entry of glioma, suependymal, specified site (brain) states see Neoplasm, uncertain behavior, by site (brain)
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Index
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ICD-10-CM Chapter 2 Index Instructions for Classifying Neoplasms 3. If the morphology is stated but the physician does not include an anatomic site, the coder should locate the morphology of the tumor in the Index to _________ and _________ Certain types of morphology indicate the anatomic site as the only possible site where the tumor will develop The physician would consider writing both the morphology and the site as redundant terminology For example, the physician documents "serous papillary carcinoma" but the site is not stated. The Index entry of carcinoma, papillary, serous or carcinoma, serous, papillary will give the codes an entry for "unspecified site" with code C56.9. The coder can _______ this entry because serous papillary carcinoma will only occur in an ovary, which is code C56.9
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Diseases Injuries trust
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If the coder is certain about the behavior of the neoplasm, for example, carcinoma is always a malignant primary tumor, the coder should reference the ICD-10-CM __________ Table as the first step. The site of the neoplasm is located and the code is selected based on the behavior of the neoplasm from the appropriate column.
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Neoplasm
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ICD-10-CM Chapter 2 Tabular List Instructions Instructional notes included to use an additional code to identify such conditions as alcohol abuse and dependence, alcohol dependence in remission, tobacco dependence, and history of tobacco use. Other instructional notes state to use an ____________ code from Chapter 4 to identify functional activity associated with any neoplasm
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additional
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ICD-10-CM Coding of the Anatomical Site Classification of Malignant Neoplasms -Malignant neoplasms are separated into __________ sites and ____________ or ____________ sites with further subdivisions by anatomic sites -Neoplasms of lymphatic and hematopoietic system are always coded to categories ____-____. These are leukemias and lymphomas, systemic conditions, and as such do not metastasize, so it would not be coded to a secondary malignant neoplasm.
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primary, secondary, metastatic, C81 C96
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ICD-10-CM Coding of the Anatomical Site Classification of Malignant Neoplasms -_____________ tumors include both malignant and benign tumors that arise from certain cells scattered throughout the body. -_____________ are either carcinoid tumors or pancreatic endocrine tumors -Many of these tumors are associated with the multiple endocrine neoplasia syndrome or carcinoi syndrome that is coded ____________
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Neuroendocrine Neuroendocrine separately
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ICD-10-CM Coding of the Anatomical Site Determination of the Primary Site -Primary site is the site where the tumor originated -Usually identified by the physician in the diagnosis -However, it is possible that the primary site cannot be determined by the physician -Neoplasm Table has an entry for this situation with first column entry of "unknown site or unspecified" and there is a code for unknown ____________ or ____________ sites
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primary, secondary
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ICD-10-CM Coding of the Anatomical Site Determination of the Primary Site -Category ____ is a code for malignant neoplasms of other and ill-defined sites, is available for use only when a more specific site cannot be identified. -This category is used only when a more specific site cannot be identified -It is also used for malignant neoplasms of ___________ sites when the point of origin cannot be determined
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C76 contiguous
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ICD-10-CM Coding of the Anatomical Site Determination of the Primary Site -Primary Malignant Neoplasms Overlapping Lesion -A tumor may develop at the junction of two parts of an organ or two organs next to each other -When the neoplasm is identified as overlapping it will be classified to the subcategory code __
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.8
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ICD-10-CM Coding of the Anatomical Site Classification of Secondary Sites -A secondary site may be referred to as a metastatic -Terms such as Metastatic to or Direct Extension to are identifying a specific site that is the ____________ site of the neoplasm or where the cancer spread to -Metastatic carcinoma of the colon to the lung -The colon is the primary site -The lung is the secondary site
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secondary
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ICD-10-CM Coding of the Anatomical Site Classification of Secondary Sites -Terms such as Spread to and Extension to identify __________ sites with metastases -Adenocarcinoma of the stomach with spread to the peritoneum -The stomach is the primary site -The peritoneum is the secondary site
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primary
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Malignant Neoplasm of Lymphatic and Hematopoietic Tissue -These conditions include lymphomas that arise out of lymph tissue, multiple myeloma that originates in bone marrow, and leukemia that forms in the blood with proliferation of abnormal leukocytes -These conditions are systemic and not isolated to a particular location and the concept of metastatic coding does not ________ to these neoplasms
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apply
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Malignant Neoplasm of Lymphatic and Hematopoietic Tissue -Lymphomas are classified according to their _______ and the specific lymph notes involved when the diagnosis was made -Multiple myeloma is classified as to whether it is stated to be in ________, in ________, or not having achieved _________ -Leukemias are classified according to their ______, such as lymphoid, myeloid or monocytic and how the condition currently exists (in remission, in relapse or not)
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type remission, relapse, achieved type
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Neoplasm-Related Pain Patient with a malignancy may seek medical care because of neoplasm-related pain. Code _______, neoplasm-related pain (acute)(chronic) is assigned to pain documented as being related to, associated, or due to a primary or secondary malignant neoplasm
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G89.3
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Neoplasm-Related Pain -Code may be principal or first-listed when the stated reason for the admission or outpatient encounter is for pain control or pain management. The underlying neoplasm is reported with it as an ____________ diagnosis. -When the reason for the admission/encounter is the management of the neoplasm and the pain associated with it is also documented, the code for the neoplasm-related pain is assigned as an additional diagnosis. The underlying neoplasm is listed ________.
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additional first
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Other Conditions Described as Malignant Meaning of the term malignant -Malignant means resistant to treatment, occurring in severe form and frequently fatal, tending to become worse and leading to an ingravescent course. -Malignant in reference to a neoplasm it means the tumor has the property of locally __________ and __________ growth and metastasis
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invasive, destructive
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Other Conditions Described as Malignant Meaning of the term malignant -Effusion is the escape of fluid from blood vessels or lymphatics into the tissues or a cavity -Fluid may accumulate in the pleural cavity, pericardium or particularly in the peritoneum called ascites -Codes for malignant ascites or malignant pleural effusion have a code first the ______________
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malignancy
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Patient admitted for HIV-related condition If a patient is admitted for an HIV-related condition, the __________ diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions.
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principal
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Patient with HIV disease admitted for unrelated condition If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the __________ diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions.
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principal
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Whether the patient is newly diagnosed Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is ___________ to the sequencing decision.
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irrelevant
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Asymptomatic human immunodeficiency virus Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of __________ is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology. Do not use this code if the term "_____" is used or if the patient is __________ for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.
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symptoms AIDS treated
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Patients with inconclusive HIV serology Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code _____, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].
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R75
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Previously diagnosed HIV-related illness Patients with any known prior diagnosis of an HIV-related illness should be coded to B20. Once a patient has developed an HIV-related illness, the patient should always be assigned code B20 on _______ subsequent admission/encounter. Patients previously diagnosed with any HIV illness (B20) should never be assigned to ____ or ____, Asymptomatic human immunodeficiency virus [HIV] infection status.
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every R75 Z21
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HIV Infection in Pregnancy, Childbirth and the Puerperium During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of ______, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 (pregnancy) always take sequencing ________. Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of ______ and _____
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O98.7- priority O98.7- Z21
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Encounters for testing for HIV If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk _________. If a patient with signs or symptoms is being seen for HIV testing, code the signs and __________. An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test. When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] _________. If the results are positive, see previous guidelines and assign codes as appropriate
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behavior symptoms counseling
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Infectious agents as the cause of diseases classified to other chapters Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In theseinstances, it is necessary to use an additional code from Chapter ___ to identify the organism.
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1
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1) Coding of Sepsis and Severe Sepsis (a) 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. A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented. (i) Negative or inconclusive blood cultures and sepsis Negative or inconclusive blood cultures do not preclude a ___________ of sepsis in patients with clinical evidence of the condition, however, the provider should be queried. (ii) Urosepsis The term urosepsis is a nonspecific term. It is not to be considered synonymous with ________. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
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diagnosis sepsis
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(iii) Sepsis with organ dysfunction If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding _______ sepsis.
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severe
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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, ___ ____ assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.
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do not
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Severe sepsis The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic ________, followed by a code from subcategory R65.2, ________ sepsis. If the causal organism is not documented, assign code _______, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.
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infection Severe A41.9
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Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For cases of septic shock, the code for the systemic infection should be sequenced _______, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be _________. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis
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first assigned
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If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as _________ diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can _______ be assigned as a principal diagnosis
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principal never
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When severe sepsis develops during an encounter (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as __________ diagnoses. Severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be _________.
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secondary queried
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Sepsis and severe sepsis with a localized infection 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 _________ diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. 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 first, ________ by the appropriate sepsis/severe sepsis codes.
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first secondary followed
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Sepsis due to a postprocedural infection (a) Documentation of causal relationship As with all postprocedural complications, code assignment is based on the provider's documentation of the ___________ between the infection and the procedure.
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relationship
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(b) Sepsis due to a postprocedural infection 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 specific _________. If the patient has severe sepsis the appropriate code from subcategory R65.2 should also be assigned with the _________ code(s) for any acute organ dysfunction.
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first infection additional
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Postprocedural infection and postprocedural septic shock In cases where a postprocedural infection has occurred and has resulted in severe sepsis and postprocedural septic shock, the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded ________ followed by code R65.21, Severe sepsis with septic shock and a code for the systemic infection.
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first
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Sepsis and severe sepsis associated with a noninfectious process (condition) In some cases a noninfectious process (condition), such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced _______, followed by the code for the resulting infection. If severe sepsis, is present a code from subcategory R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is _____ necessary to assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, for these cases. If the infection meets the definition of principal diagnosis it should be sequenced _______ the non-infectious condition. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis either may be assigned as principal diagnosis. Only ____ code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a non-infectious condition leads to an infection resulting in severe sepsis, assign the appropriate code from subcategory R65.2, Severe sepsis. Do not additionally assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin.
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first not before one
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Bacterial Sepsis of Newborn Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis ________ documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned. If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should ______ be assigned. If the P36 code does not include the causal organism, assign an additional code from category B96. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.
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without not
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Puerperal sepsis Code O85, Puerperal sepsis, should be assigned with a __________ code to identify the causal organism (e.g., for a bacterial infection, assign a code from category B95-B96, Bacterial infections in conditions classified elsewhere). A code from category A40, Streptococcal sepsis, or A41, Other sepsis, should _____ be used for puerperal sepsis. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.
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secondary not
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Combination codes for MRSA infection When a patient is diagnosed with an infection that is due to methicillin resistant Staphylococcus aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., sepsis, pneumonia) assign the appropriate _____________ code for the condition (e.g., code A41.02, Sepsis due to Methicillin resistant Staphylococcus aureus or code J15.212, Pneumonia due to Methicillin resistant Staphylococcus aureus). Do not assign code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, as an additional code because the combination code ________ the type of infection and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to penicillins, as an additional diagnosis
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combination includes
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Other codes for MRSA infection When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a __________ code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere for the MRSA infection. Do not assign a code from subcategory Z16.11, Resistance to penicillins.
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combination
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Methicillin susceptible Staphylococcus aureus (MSSA) and MRSA colonization The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MSRA is present on or in the body without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as "MRSA screen positive" or "MRSA nasal swab positive". Assign code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, for patients documented as having MRSA ___________. Assign code Z22.321, Carrier or ___________ carrier of Methicillin susceptible Staphylococcus aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider
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colonization suspected
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MRSA colonization and infection If a patient is documented as having both MRSA colonization and infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, and a code for the MRSA infection may _______ be assigned.
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both
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Treatment directed at the malignancy If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.-- code as the _______-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
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first
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Treatment of secondary site 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 __________ diagnosis even though the primary malignancy is still present.
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principal
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Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the __________ or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).
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principal
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Anemia associated with chemotherapy, immunotherapy and radiation therapy When the admission/encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the __________ code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect (T45.1X5, Adverse effect of antineoplastic and immunosuppressive drugs).
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anemia
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When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced ________, followed by the appropriate neoplasm code and code _______, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
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first Y84.2
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Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the ___________ is sequenced first, followed by the code(s) for the malignancy.
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dehydration
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Treatment of a complication resulting from a surgical procedure When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the ____________ as the principal or first-listed diagnosis if treatment is directed at resolving the complication
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complication
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Primary malignancy previously excised 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 Z85, ___________ history of malignant neoplasm, should be used to indicate the former site of the malignancy. 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 ___________ or first-listed with the Z85 code used as a secondary code
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Personal principal
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Episode of care involves surgical removal of neoplasm When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the __________ should be assigned as principal or first-listed diagnosis.
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neoplasm
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Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, ___________ for antineoplastic radiation therapy, or Z51.11, ____________ for antineoplastic chemotherapy, or Z51.12, ____________ for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence. The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis. (((((Blanks all the same word)))))
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Encounter
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Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is Z51.0, ___________ for antineoplastic radiation therapy, or Z51.11, ___________ for antineoplastic chemotherapy, or Z51.12, ___________ for antineoplastic immunotherapy followed by any codes for the complications. (((((Blanks all the same word)))))
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Encounter
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Admission/encounter to determine extent of malignancy When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the ___________ or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
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principal
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Symptoms, signs, and ill-defined conditions listed in Chapter 18 characteristic of, or associated with, an existing primary or secondary site malignancy __________ be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.
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cannot
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Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic. This code may be assigned as the __________ or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an ___________ diagnosis. It is not necessary to assign an additional code for the site of the pain.
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principal additional
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Malignancy in two or more noncontiguous sites A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending on the site. Should the documentation be unclear, the provider should be __________ as to the status of each tumor so that the correct codes can be assigned
answer
queried
question
Disseminated malignant neoplasm, unspecified Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known _________ or _________ sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.
answer
primary, secondary
question
Malignant neoplasm without specification of site Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the __________ site of a malignancy. This code should rarely be used in the inpatient setting.
answer
primary
question
Encounter for treatment of primary malignancy If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The __________ site is to be sequenced first, followed by any metastatic sites.
answer
primary
question
Encounter for treatment of secondary malignancy When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the ___________ site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.
answer
metastatic
question
Malignant neoplasm in a pregnant patient When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced _______, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.
answer
first
question
Encounter for complication associated with a neoplasm When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the ___________ is coded first, followed by the appropriate code(s) for the neoplasm. The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the __________ is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.
answer
complication malignancy
question
Complication from surgical procedure for treatment of a neoplasm When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the ___________ as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the __________ should also be assigned.
answer
complication neoplasm
question
Pathologic fracture due to a neoplasm 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 sequenced _______, followed by the code for the neoplasm. If the focus of treatment is the neoplasm with an associated pathological fracture, the _________ code should be sequenced first, followed by a code from M84.5 for the pathological fracture
answer
first neoplasm
question
Current malignancy versus personal history of malignancy 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 ___________. 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 Z85, ___________ history of malignant neoplasm, should be used to indicate the former site of the malignancy
answer
completed Personal
question
Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved __________. There are also codes Z85.6, Personal _________ of leukemia, and Z85.79, Personal _________ of other malignant neoplasms of lymphoid, hematopoietic and related tissues. If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried
answer
remission history history
question
If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced ______, followed by the appropriate personal history and genetic susceptibility codes
answer
first
question
Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be _______-listed, followed by the diagnosis code when a patient's encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm
answer
first
question
Prophylactic Organ Removal For encounters specifically for prophylactic removal of an organ (such as prophylactic removal of breasts due to a genetic susceptibility to cancer or a family history of cancer), the __________or first-listed code should be a code from category Z40, Encounter for prophylactic surgery, followed by the appropriate codes to identify the associated risk factor (such as genetic susceptibility or family history).
answer
principal
question
If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in __________ to a code from subcategory Z40.0, Encounter for prophylactic surgery for risk factors related to malignant neoplasms. A Z40.0 code should not be assigned if the patient is having organ removal for treatment of a ___________, such as the removal of the testes for the treatment of prostate cancer
answer
addition malignancy
question
Malignant neoplasm associated with transplanted organ A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, ___________ of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an ___________ code for the specific malignancy.
answer
Complications additional
