question

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM

answer

the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

question

The term encounter is used

answer

for all settings, including hospital admissions.

question

Section I - Conventions, General Coding Guidelines, and Chapter Specific Guidelines

answer

The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. This section is the largest section of the guidelines The conventions, general guidelines, and chapter-specific guidelines in Section I are applicable to all healthcare settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines.

question

Section II - Selection of Principal Diagnosis

answer

Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner.

question

When two or more interrelated conditions are present that qualify for principal diagnosis, either may be listed first.

answer

true

question

Possible diabetes mellitus would be reported using the code for diabetes mellitus in the physician setting.

answer

false

question

The patient is admitted to the observation unit of the hospital for chest pain. The next day he is admitted to the inpatient floor because of worsening of symptoms and a diagnosis of acute myocardial infarction. The principal diagnosis for the hospital is chest pain.

answer

false

question

The discharge summary for the inpatient stay lists: abdominal pain due to either acute diverticulitis or acute colitis. What is the principal diagnosis?

answer

acute diverticulitis or acute colitis

question

The patient came to the surgery center for dilation of esophageal stricture. After anesthesia was administered he experienced arrhythmia, diagnosed as atrial fibrillation, and was admitted to the hospital for treatment. What is the principal diagnosis for the hospital inpatient stay?

answer

atrial fibrillation

question

Section III - Reporting Additional Diagnoses

answer

Section III includes guidelines for reporting additional diagnoses in non-outpatient settings.

question

General Rules for Other (Additional) Diagnoses

answer

For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring

question

The UHDDS item #11-b defines Other Diagnoses as

answer

"all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short-term, long term care, and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. The guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider.

question

t/f Section III of the ICD-10-CM Coding Guidelines applies to physicians and outpatient services.

answer

false

question

t/f History codes (Z80-Z87) are not used in the inpatient setting.

answer

false

question

The patient was in the hospital for dehydration. It was documented by the provider that the blood sugar was extremely high, and the patient was evaluated for diabetes mellitus and started on insulin. Dehydration and diabetes mellitus are coded at discharge.

answer

true

question

The inpatient coder notices that the echocardiogram report (interpreted by a physician) has the diagnosis of mitral valve prolapse. This diagnosis was not documented by the provider. At discharge the coder codes mitral valve prolapse as an additional diagnosis.

answer

false

question

The patient is admitted for pneumonia. The coder notices low potassium levels in the laboratory report. The physician documents palpitations and prescribes IV potassium chloride. What should the coder do?

answer

query the physician to see if the hypokalemia should be added

question

Section IV - Diagnostic Coding and Reporting Guidelines for Outpatient Services

answer

Section IV is for outpatient coding and reporting

question

Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles) can be found in

answer

Section IA of these guidelines under "Conventions Used in the Tabular List." Information about the correct sequence to use in finding a code is also described in Section I.

question

t/f The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.

answer

true

question

Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:

answer

The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals. Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.

question

Section IV ICD-10 Guidelines are used by physician services.

answer

TRUE

question

Encounter and visit can be used interchangeably in the outpatient setting.

answer

TRUE

question

In the physician office, the term principal diagnosis is used.

answer

FALSE

question

The patient comes to outpatient surgery for a tonsillectomy for chronic tonsillitis. After recording the temperature, the surgery was postponed because of an acute upper respiratory infection. The acute upper respiratory infection is coded as the primary diagnosis for the encounter.

answer

FALSE

question

Sign/symptom codes are appropriate when an established diagnosis has not been made.

answer

TRUE

question

The code for acute myocardial infarction would be assigned for the diagnosis of possible acute MI in the emergency room.

answer

FALSE

question

Chronic diseases that are being treated may be coded as many times as necessary.

answer

TRUE

question

The order for the test states: Rule out mitral valve prolapse. The outpatient coder notices that the echocardiogram report (interpreted by a physician) has the diagnosis of mitral valve prolapse.The coder codes mitral valve prolapse.

answer

TRUE

question

What code is assigned for routine laboratory testing when there are no signs or symptoms? _____

answer

Z01.89

question

Appendix I - Present on Admission Reporting Guidelines

answer

These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional). how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA indicator should then be assigned to those conditions that have been coded

question

2015 ICD-10-CM Guidelines

answer

2015 ICD-10-CM Guidelines.pdf

question

t/f? If there is inconsistent or missing documentation by the provider, the coder can make the best choice to assign the POA.

answer

false

question

What is considered present on admission?

answer

present at time the order for inpatient admission occurs conditions developing during an outpatient encounter conditions developing during outpatient surgery

question

When may the POA field be left blank?

answer

the POA condition is on the exempt from reporting list

question

What POA indicator would be assigned for asthma diagnosed 1 year ago?

answer

Y

question

What POA indicator would be assigned for atrial fibrillation that occurred during outpatient surgery when the patient was subsequently admitted to inpatient status for treatment?

answer

Y

question

What POA indicator would be assigned for sepsis that when queried, the provider states she is not sure if it occurred before or after admission?

answer

W

question

What POA indicator would be assigned for a fractured hip when the patient fell out of bed during the hospital admission?

answer

N

question

What POA indicator would be assigned for pneumonia that developed four days after the patient's admission, requiring prolonged stay and care?

answer

N

question

POA - Y

answer

present at the time of inpatient admission

question

POA - W

answer

provider is unable to clinically determine whether condition was present on admission or not

question

POA - U

answer

documentation is insufficient to determine if condition is present on admission

question

POA - N

answer

not present at the time of inpatient admission

question

The ICD-10-PCS is a

answer

procedure classification published by the United States for classifying procedures performed in hospital inpatient health care settings. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-PCS: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

question

The parts of the ICD-10-PCS Guidelines are listed

answer

A - Conventions B - Medical and Surgical Section Guidelines 2. Body System 3. Root Operation 4. Body Part 5. Approach 6. Device C - Obstetrics Section Guidelines

question

ICD-10-PCS CODING ; REPORTING GUIDELINES

answer

http://training.careerstep.com/pdf/PMCB/ICD-10-PCS_2015_Guidelines.pdf

question

How many characters are used in all ICD-10-PCS codes?

answer

7

question

The Medical and Surgical Section of ICD-10-PCS begins with the value 0. What Is the meaning of the fifth axis or character in the code?

answer

approach

question

In ICD-10-PCS, which is a valid code?

answer

A9 Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. In the example below, 0JHT3VZ is a valid code, and 0JHW3VZ is not a valid code.

question

When the physician documents partial resection the coder equates that to which ICD-10-PCS root operation?

answer

excision

question

T/F? It is always required to use the Index first before assigning an ICD-10-PCS code.

answer

False.

question

In the ICD-10-CM Official Guidelines, the term encounter is used in _____.

answer

all settings

question

In the ICD-10-CM Official Guidelines, provider means _____.

answer

physician or any qualified health care practitioner legally accountable for a diagnosis

question

Who uses Section II of the ICD-10-CM Official Guidelines for Coding and Reporting?

answer

hospital inpatient nursing homes psychiatric hospitals

question

The diagnosis is probable cirrhosis of the liver. Which setting would report K74.60 (code for cirrhosis of the liver)?

answer

hospital inpatient

question

The diagnostic statement is _____.

answer

*congestive heart failure* history of lung cancer history of hypertension pneumonia (resolved 1 year ago)

question

Which diagnosis would not be coded in the hospital inpatient setting?

answer

congestive heart failure history of lung cancer diabetes mellitus, type 1 *pneumonia (resolved 1 year ago)*

question

POA indicators are assigned in the inpatient setting for_____.

answer

principal diagnosis secondary diagnoses external cause of injury codes

question

What is the purpose of the Alphabetic Index in ICD-10-PCS?

answer

used to locate the appropriate table to construct the code

question

Inconclusive diagnoses do not apply to outpatient services.

answer

true

question

t/f? When coding the diagnosis, it is appropriate to begin searching in the Tabular List for the code.

answer

false

question

t/f? When 7th characters are indicated in the code set, it is appropriate to leave off the 7th character for the ICD-10-CM diagnosis code when reporting in the outpatient/physician setting.

answer

false

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