ICD-9 Outpatient – Flashcards
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Answer: Access the Coding Clinic It is the coding clarification source for all coders.
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Outpatient: Question: What should Coders do if they come across a complex ICD-9 coding issue while coding radiology reports that they are not sure how to code something?
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V22.0, supervision of normal first pregnancy V22.1, supervision of other normal pregnancy (For complications of pregnancy, the above codes are not reported with codes 630-679)
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Outpatient: Routine Outpatient Prenatal Visits This guideline for prenatal visits applies when the prenatal visit occurs and the patient has no current complications. Under these circumstances, the first-listed diagnosis is reported as either:
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- The current or primary cancer site should be coded. -If the patient is no longer being treated for cancer and it is clearly documented that the patient no longer has cancer, only the history of cancer should be coded -Use the observation and evaluation codes (V71.X) when no other indication is listed e.g. Assign code V71.1, for observation for suspected malignant neoplasm, as the primary dx for PET scans, when the scan is being done to determine "potential" spread of a malignancy
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Outpatient: Diagnostic Radiology Coding Outpatient Coding Challenges: Another confusing situation is when "rule-out metastasis" is ordered.
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Code original cancer site along with any findings If there are no findings, only the original cancer site should be coded
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Outpatient: Example3: Indication for test: Rule-out metastasis Findings: Normal x-ray What to Code:
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If there is a good symptom provided, only that symptom is coded. V71 should not be added as a secondary code If no signs or symptoms are documented, then the V71.xx code is appropriate
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Outpatient: Diagnostic Radiology Coding Outpatient Coding Challenges: Common Rule-Out Challenges Example1: Indication for test: Rule-out pneumonia Findings: Normal chest x-ray Coded as?
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If there is a good symptom provided, only that symptom is coded. V71 should not be added as a secondary code. If no documentation of signs or symptoms, then assign the V71.xx code Note: This is same as the previous screen's example with "normal" findings on the radiology reports
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Outpatient: Diagnostic Radiology Coding Outpatient Coding Challenges: Example2: Indication for test: Rule-out appendicitis Findings: Normal abdominal x-ray What to Code?
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A common follow-up exam is for fracture aftercare For follow-up of a fracture, coders can use V54.X (other orthopedic aftercare) as the primary diagnosis
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Outpatient: Also, many coders are faced with rule-out diagnosis when the patient is receiving follow-up or aftercare
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Code V54.x (other orthopedic aftercare)
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Outpatient: Example4: Indication for test: Follow-up fracture Findings: Normal x-ray What to Code:
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"Trauma" alone cannot be coded as an injury and should instead assigned as V71.4 (observation following other accident) Answer: Trauma is not always indicative of injury. If there are no findings after diagnostic testing, assign code V71.4, Observation following other accident. However, the patient presents with symptoms (i.e., pain, swelling, tenderness, etc.) assign the appropriate code for the symptoms.
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Outpatient: What is coded if the reason for the radiology service is specified only as "trauma"? e.g. CT scan following trauma: Question: CT scan ordered for treatment of injuries sustained for patient following an accident. Reason for the CT is documented on report as "trauma". How should this be coded?
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These are probable or suspected conditions that cannot be coded in the outpatient setting. Coders should code to the highest degree of certainty for the particular encounter, using indicators such as signs or symptoms or other positive findings in the medical report (Vol. 22, No. 3, third quarter, 2005)
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Outpatient: How should unconfirmed diagnoses described in terms such as "consistent with," "compatible with," "indicative of," "suggestive of," and "comparable with" be coded in the outpatient setting?
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Code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis
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Outpatient: Diagnostic Test Ordered Due to Signs and/or Symptoms If the physician has confirmed a diagnosis based on the results of the diagnostic test, the coder should ___________?
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Dx code: diverticulitis 562.11 The abdominal pain would not be coded as it is a symptom of the diverticulitis.
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Outpatient: Example: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals numerous diverticula in the cecum and descending colon. The Impression on the CT report states a diagnosis of "diverticulitis with no evidence of diverticular abscess.
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The sign(s) or symptom(s) that prompted the treating physician to order the study should be coded. The radiologist should report a diagnosis of "knee pain" since this was the reason for performing the X-ray - Dx Code: 719.46 knee pain
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Outpatient: What should be coded if the diagnostic test did not provide a diagnosis or was normal? Example: A patient is referred to a radiologist for a X-ray due to complaints of "knee pain". The radiologist performs the x-ray, and the results are normal.
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Do not code that diagnosis but instead, report the sign or symptom/s that prompted the study.
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Outpatient: How should the results of diagnostic test are normal or non-diagnostic be coded when the referring physician records a diagnosis preceded by words that indicate uncertainty such as probable, suspected, questionable, rule out, or working?
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Incidental findings would not be coded. Refer back to the reason for the test at the top of the radiology report or the physician order. The reason for the testing would be the primary diagnosis.
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Outpatient: If the Impression or Conclusion of the radiology report is an incidental finding and the radiologist states "incidental" then how would this be coded?
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The reason for the test should be coded, such as if it was a screening or what kind of testing it is being performed. If there are findings, then those would be coded as additional diagnoses Dx Code: V76.12 for the screening and 793.89 for the breast calcification.
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Outpatient: Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms (e. g. screening tests) When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury and therefore no diagnosis documented on the order, Example: Asymptomatic patient coming in for a Screening mammogram, The mammogram Impression states breast calcifications are found. How should this be coded?
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Look closely at the order to see if this is an order for a Screening Mammogram or a Diagnostic Mammogram.Orders for Screening Mammograms will be documented as "Screening" or it will be checked marked off as Screening. Orders for Diagnostic Mammograms will be documented as "Diagnostic and there will usually be a dx on that order for the reason for the test. Mammograms will be identified as either Screening or Diagnostic at the top of the report- be sure to look for this.
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Outpatient: Mammograms: Screening Mammograms Codes V76.12, V76.11 Diagnostic Mammograms An ICD-9 code that describes the patient's documented signs or symptoms such as a lump, pain, thickening, a change in size or shape of the breast
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Answer: Assign code V76.12, Special screening for malignant neoplasm for this encounter
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Outpatient: Screening Mammogram: Coding Clinic, Second Quarter 2003 Question: A healthy 40-year-old woman presents to the radiology department for a screening mammogram. The patient has no symptoms or known risks for breast cancer. How should this be coded?
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Answer: Assign code V76.12, Special screening for malignant neoplasm, Breast, as the first listed diagnosis, since this was a screening mammogram Even though a mass was found in the breast, the current visit for the mammogram is still considered a screening. Assign code 611.72, Lump or mass in breast, as an additional diagnosis
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Outpatient: Screening mammogram with positive findings Coding Clinic, Second Quarter 2003 Page: 4 Question: An asymptomatic 65-year-old woman has a screening mammogram, which revealed a breast mass
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Answer: Assign code V76.11, Special screening for malignant neoplasm, Breast, Screening mammogram for high-risk patient, as the first-listed diagnosis, followed by code V16.3, Family history of malignant neoplasm, Breast Note: High risk factors include a family history of breast cancer.
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Outpatient: Screening mammogram due to family history Coding Clinic, Second Quarter 2003 Page: 4 Question: A woman with no symptoms is referred for screening mammogram. The patient is considered high risk for breast cancer secondary to a family history of breast malignancy in the mother and sister. How should this encounter be coded?
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CMS considers the following patients to be high risk: -personal history of breast cancer (V10.3) • family history of breast cancer (V16.3) (In Mother, Sister) • In Daughter • Had her first baby after age 30 (V15.89) • Has never had a baby (V15.89) If there is documentation of these conditions then assign V76.11 as primary dx, with above conditions as a secondary dx
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Outpatient: Screening Mammograms- Codes V76.11 High Risk What constitutes "high risk"?
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Screening mammogram with known fibrocystic disease Answer: Assign code V76.12, Special screening for malignant neoplasm, Other screening mammogram, as the first-listed diagnosis. Code 610.1, Diffuse cystic mastopathy, should be assigned as an additional diagnosis Fibrocystic breast disease is a normal variant, commonly found in normal breasts usually consisting of lumps Also called diffuse cystic mastopathy chronic cystic mastitis, fibrocystic mastopathy and mammary dysplasia. This exam would still be considered a screening mammogram and code V76.12 assigned as the first-listed diagnosis
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Outpatient: Screening mammogram with known fibrocystic disease Coding Clinic, Second Quarter 2006 Page: 10 Question: The physicians at our facilities order routine screening mammograms for patients with known fibrocystic disease of the breasts Based on the guideline for screening that it is the testing for disease or disease precursors in seemingly well individuals it seems that code V76.12 would not be used since fibrocystic breast disease is documented What should be the first-listed code for a screening mammogram on patients with fibrocystic disease of the breast?
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False. Diagnostic mammograms differ from screening mammograms. Screening mammograms are for patients without apparent problems. Diagnostic mammograms are performed when there IS a problem identified, such as a breast mass, pain, discharge, etc. Diagnostic mammograms should have a diagnosis, sign, symptom or other problem documented
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Outpatient: Diagnostic mammograms: Question: True/False? A diagnostic and screening mammograms are essentially the same and coded as such.
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Answer: Code any positive findings found on the diagnostic mammogram. If there are no reported findings, assign the reason for the test as the first listed diagnosis. In this instance, assign code 611.72, Lump or mass in breast. Do not assign code V76.12, Special screening for malignant neoplasm, Breast, because this was not a screening mammogram.
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Outpatient: Diagnostic mammograms: A patient with a breast mass is referred to the radiology department for diagnostic mammogram. How should this be coded?
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Answer: -When a follow-up exam is done to determine if there is any evidence of recurring or metastasizing cancers and no evidence of malignancy is found, this is classified to the V67 category for follow-up -Assign code V10.3, Personal history of malignant neoplasm, Breast, as an additional diagnosis - If the follow-up examination demonstrates recurrence or metastasis, a follow-up code from category V67 would not be used.
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Outpatient: Follow-up mammogram Coding Clinic, Second Quarter 2003 Page: 5 Question: An asymptomatic patient with a history of breast cancer who is currently disease-free is referred for follow-up mammogram. What is the correct code assignment for this encounter?
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It may be used in conjunction with other codes related to the patient's health status (V49.81, Postmenopausal status, and V07.4, Postmenopausal hormone replacement therapy). The screening code should be listed before the status codes. V82 Special screening for other conditions V82.8X Other specified conditions V82.81 Osteoporosis V82.89 Other specified conditions
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Outpatient: Encounters for osteoporosis screening: Osteoporosis screening - Dexa Bone Scan Code V82.8X, Other specified conditions, has been expanded with two new codes. A new code has been added for encounters for osteoporosis screening. This code is to identify the patient who presents for osteoporosis screening who is otherwise asymptomatic
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Answer: Assign code V82.81, Special screening for osteoporosis. Code V49.81, Postmenopausal status, may be used as an additional diagnosis
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Outpatient: Question: A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter?
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Note: Physicians will use the terms "asthma" and "reactive airway disease" (RAD) interchangeably. When you see it documented as RAD it codes to 493.90 which codes to asthma unless it is documented by the physician "RAD, NOT as asthma" If the dx states " RAD Not as asthma" then the code assigned is 519.9 unspec disease of respiratory
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Outpatient: Note: Physicians will use the terms "asthma" and "reactive airway disease" (RAD) interchangeably. When you see it documented as RAD it codes to 493.90 which codes to asthma unless it is documented by the physician "RAD, NOT as asthma" If the dx states " RAD Not as asthma" then the code assigned is 519.9 unspec disease of respiratory
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Category V23 (Supervision of high-risk pregnancy) Code this as the principal or first-listed diagnosis These codes may be used in conjunction with pregnancy complication codes
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Outpatient: Selection of Obstetric Principal or First-listed Diagnosis: Prenatal outpatient visits for high-risk patients?
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Use subcategory 648.X for patients who have current conditions when the condition affects the management of the pregnancy, childbirth, or the puerperium. Use additional codes to identify the conditions, as appropriate. e.g. 1.) Code: 648.23 (other current conditions in mother classifiable elsewhere, but complicating pregnancy, antepartum) + 285.9 (anemia, unspec.) 2.) Code: 648.93 (current condition in mother complicating pregnancy, antepartum) + 496 (COPD)
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Outpatient: Current Conditions Complicating Pregnancy? 1.) Example: Patient is 39 weeks pregnant with slight anemia and is treated with iron? 2.) Example: the patient is 25 weeks pregnant and has COPD. Patient has a chest X-ray done?
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1.) Situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. 2.) Treatment is directed at a current, acute disease or injury; the diagnosis code is to be used in these cases. 3.) Fitting and adjustment, and attention to artificial openings. 4.) True
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Outpatient: Categories of V Codes - Aftercare: 1.) Aftercare visit codes cover __________? 2.) The aftercare V codes should not be used if _________? 3.) Additional V code aftercare category terms include ____________? 4.) True/False? Status V codes may be used with aftercare V codes to indicate the nature of the aftercare.
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Code: V54.19 aftercare for healing traumatic fx of bone.
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Example: X-ray done after definitive fracture treatment of ankle. Dx on X-ray order and Indication of report states "Healing traumatic fx of ankle". How is this coded?
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Answer: Assign code V67.4, Follow-up examination, Following treatment of healed fracture, for the encounter. This is a follow-up visit for a healed fracture. A code from category V67 is used as the first-listed diagnosis when a patient is seen for evaluation after treatment of a disease or injury has been completed and the condition no longer exists
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Outpatient: Aftercare terms to watch for in regards to fractures: "Healed" vs. "Healing" Follow-up visit for healed fracture: (Note: term "healed") Patient is an 18-year-old male who had previously sustained a comminuted right distal tibial fracture that had been treated. Is now being seen for follow-up X-rays. Conclusion states "Complete alignment and union of fracture with full range of motion" Is code V54.16 Aftercare for healing traumatic fracture of lower leg, assigned for this encounter?
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Search under "admission for, examination" In these cases, code V70.5, Health examinations would be the first listed diagnosis.
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Outpatient Visits: An example of an outpatient visit: When a patient comes in for pre-employment physical exam You may see a lab order with a dx of pre-employment physical
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First listed diagnosis in this case would be V58.83 Encounter for therapeutic drug monitoring of the medication Coumadin Additional dx code V58.61 would also be used to describe long-term use of the anticoagulant
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Outpatient Visits: Another example: A patient who is on Coumadin therapy may be required to visit a Coumadin clinic weekly until the levels of medication are adjusted Lab order dx would be Coumadin monitoring
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Step 1: Review the complete outpatient documentation Step 2: Abstract the confirmed diagnoses to be coded based on that documentation Step 3: Assign the correct ICD-9-CM diagnosis codes, following the ICD-9-CM rules and conventions. Step 4: Sequence the codes based on Section IV of the ICD-9-CM Official Guidelines
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Outpatient: Outpatient Code Assignment Flow: 4 steps
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Primary dx code would be V57.1 for Physical therapy, as the reason chiefly responsible for the patient's visit Code 719.46 for the knee pain, which is the problem for which the service is being done. This would be assigned second
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Outpatient: Patients may receive only therapeutic services: procedures done to treat conditions and injuries - during outpatient visits. The ICD-9-CM code reported first represents the diagnosis, condition, problem, or other reason for the encounter Examples: Physical Therapy, Occupational Therapy, Speech Therapy For example: Physical therapy order for PT with a dx of knee pain documented
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A code from category V72.8 is sequenced first A fifth digit is required to indicate the type of pre-operative exam The reason for the surgery is coded as an additional diagnosis Codes would be V72.63 Pre-procedural lab exam as first listed code and 401.9 for the HTN as an additional code
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Outpatient: When a patient receives a preoperative evaluation only, For example: A patient is planning surgery for an abdominal aortic aneurysm The patient's primary care physician sends her for lab work for pre-op evaluation. On the lab order it is documented "Pre-op eval, HTN"
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V22.0, supervision of normal first pregnancy V22.1, supervision of other normal pregnancy These codes are only acceptable as the primary diagnosis For complications of pregnancy, the above codes of V22.0 and V22.1 are NOT reported with codes 630-677
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Outpatient: Routine Outpatient Prenatal Visits The guideline for prenatal visits applies when the prenatal visit occurs and the patient has NO current complications These are assigned as:
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Patient who will be 35 yrs or older at expected time of delivery. Patient who will be 16 yrs or less at expected time of delivery. Codes would be: V23.81 elderly primigravida V23.82 elderly multigravida V23.83 young primigravida V23.84 young multigravida
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Outpatient: ICD defines high risk pregnancy as:
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V23.41 history of pre-term labor V23.42 history of ectopic pregnancy V23.49 other poor obstetric history V23.3 grand multiparity
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Outpatient: Poor obstetric history includes:
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For these encounters where they are checking for viability assign code V23.87 "Pregnancy with inconclusive fetal viability"
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Outpatient: This V code is assigned as the reason for an encounter to determine the viability of the pregnancy Example: during the early weeks of pregnancy, it may be difficult for the physician to determine fetal viability. When the fetal heartbeat is not heard, an ultrasound is needed to confirm that the pregnancy is viable.
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1.) Admission 2.) Examination 3.) History 4.) Observation 5.) Aftercare 6.) Problem 7.) Status
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Chapter 8 V Codes: V codes are included in the alphabetic index under the following 7 key main terms:
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When the sole purpose of the encounter is 1.)specific aftercare for a resolving disease, injury, or chronic condition. (e.g. removal of orthopedic pins) 2.) special therapy. (e.g. radiotherapy, chemotherapy, dialysis) 3.) other specific reason as opposed to illness or injury: (e.g.organ donor, prophylactic [preventative] care, counseling etc.) 4.) indicating the birth status of newborns.
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Chapter 8 V Codes: V codes are used as the principle (or first-listed) diagnosis in the following four situations:
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1.) to indicate that patient has a history, health status, or other problem that is not in itself an illness or injury but may influence patient care. 2.) To indicate the outcome of delivery for obstetric patients.
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Chapter 8 V Codes: V codes are assigned as additional diagnosis codes in the following two situations:
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1.) When the patient history itself is the reason for the admission or encounter. 2.) - V10x = personal hx. of malignant neoplasm - V12.4 = personal hx. of disorders of nervous system and sense organs. - V16 - V19 = family history
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Chapter 8 V Codes: 1.) In what situation can a V code used to indicate patient history be assigned as principle (or first listed)? 2.)Which codes are assignable in this manner?
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1.) Aftercare codes. 2.) Aftercare management incuding: - continued care during healing phase - fitting or adjustment of prosthetics, reconstruction following mastectomy, removal of fixation device, rehab (additional code for residual condition required with rehab) - aftercare of Fx (e.g. cast change/removal) - following surgery 3.) Generally listed first to explain reason for encounter
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Chapter 8 V Codes: 1.) V51 - V58 are? 2.) For what four purposes are they generally assigned? 3.) How are they generally sequenced?
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False. The appropriate code for the complication listed under the main classification is assigned rather than an aftercare V code.
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Chapter 8 V Codes: True/False a V51 - V58 (aftercare V code) is typically assigned when a patient is admitted because of a complication of previous care.
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1.) V67.x 2.) Followup V code is only assignable when no new conditions are found or treated and the followup exam remains the sole purpose for the admission. If new conditions are found/treated during the exam then the additional conditions/treatments are coded & V67.x is not assigned.
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Chapter 8 V Codes: 1.) What V code category is assigned as a principle diagnosis when a patient is admitted for the purpose of surveillance after the initial treatment of a disease or injury has been completed (followup examination)? 2.) When can a followup V code be assigned.
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1.) V67.51 2.) V58.xx
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Chapter 8 V Codes: 1.) V code designated for a followup examination following treatment with high risk medication when patient is no longer on medication? 2.)V code designated for followup examinations of patients currently on long-term therapeutic medication?
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V71.xx
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Chapter 8 V Codes: Code category for observation and evaluation of suspected condition that is not found?
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A. 1.) the suspected condition is found (in this case, the condition is coded & V71xx is not assigned.) 2.) a patient is admitted to a hospital for observation immediately following same day (outpatient) surgery. B. 1.) V29, 2.) V89.xx
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Chapter 8 V Codes: A. V71.xx are not assigned when 1.)_____or when 2.)_____? B. Other observation codes include 1.) _______ for observation of a newborn and 2.)_______ designating observation for maternal and fetal conditions unconfirmed.
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The condition that provided the original reason for the outpatient observation.
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Chapter 8 V Codes: If a patient is admitted after a period in the outpatient observation unit for further evaluation unrelated to surgery the principle diagnosis is ________?
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False. V66.7 can not be a principle (or first listed) diagnosis. The underlying disease/condition is listed first.
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Chapter 8 V Codes: True/False V66.7 designating admission for palliative/hospice/end-of-life care can be a principle (or first listed diagnosis?
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True
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Chapter 8 V Codes: True/False V72.x designating "special investigative examinations" are only assigned as the reason for the encounter when no problem, symptom, diagnosis or condition is identified as the reason for the examination These designations are rarely appropriate for inpatient examinations and never assigned as additional codes.
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V72.xx + code designating underlying condition for which surgery was planned.
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Chapter 8 V Codes: What is the appropriate sequencing when V72.xx (special investigative examinations) codes are assigned preoperative evaluations?
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1.) V73 - 82 2.) These codes are sequenced as: a.) V code only b.) V code as 1st or principle + code for condition or pathology.
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Chapter 8 V Codes: 1.) What is the range of V codes used to designate screening examinations? 2.) How are they sequenced when: a.) no pathology found? b.) pathology identified in screening?
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Physician has documented in report that patient is high-risk.
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Chapter 8 V Codes: V codes 76.11 (screening for high-risk patient) is only used when________?
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1.) a personal history of a previous condition 2.) a family history, are assigned when family history is the reason for examination or treatment.
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Chapter 8 V Codes: 1.) personal history codes V10 -V15 are used to indicate____? 2.) Family history codes V16 -V19 are assigned to indicate ______?
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1.) Status codes (V40 -V49) 2.) History codes = problem no longer exists Status codes = problem is present/on-going
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1.) These V codes are used to indicate a continuing condition that may influence care (e.g. pt. is a carrier of a disease, has a pacemaker, tracheostomy etc.) 2.) What is the main difference between these (V codes mentioned above) and history V codes?
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Problem codes.
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Chapter 8 V Codes: V60 -V63 are ________ codes which indicate other factors such as homelessness, social maladjustment, economic or job concerns which may affect patient care or prevent satisfactory compliance.
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Categories from V10, V12., and some V13s V15.88 V16 - V19
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Chapter 8 V Codes: History, Status, and Problem codes ordinarily can not be used as the principle diagnosis except for which exceptions?
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1.) Codes from category V84 are used to report genetic susceptibility to disease. 2.) False. Codes from category V84 should not be used as principle (or first listed) diagnosis. 3.) The sequencing of V84 codes depend on the circumstances of the encounter.
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Chapter 8 V Codes: 1.) Codes from category V84 are used to report________? 2.) True/False these codes can be used as principle diagnosis. 3.) The proper sequencing of these codes depend on______?
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True
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Chapter 8 V Codes: True/False? Many V codes may be assigned as the principle (or first listed) diagnosis or as secondary diagnosis. However, ICD-9-CM "Official Guidelines for Coding and Reporting" contains a list of V codes that may only be reported as principle/first listed diagnosis. Codes from this list should not be reported if they do not meet the definition of principle or first listed diagnosis.
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1.) Chapter 1 2.) The organism responsible for the condition.
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1.) This Chapter of the ICD-9-CM classifies infectious and parasitic diseases that are easily transmittable. 2.) The primary axis for organization of this chapter is by________?
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1.) A single code assigned to designate the organism: e.g. 072.x = mumps 2.) Combination codes to identify the condition and the organism. e.g. Pneumonia due to Staphylococcus aureus = 482.41 3.) Dual Classification e.g. Pneumonia = 484.3 due to Whooping cough (Bordetella pertussis) = 033.0 (sequenced as: 033.0 Bordetella pertussis + Pneumonia 484.3)
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Infectious and parasitic diseases are classified in one of several ways including:
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The organism always takes precedence. In the example, Cystitis (bacillary), monilial 112.2x would be the correct selection.
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In an index search for an infection where a main term contains indented subterms including those to indicate organism and others to indicate (acute) (chronic) e.g. For a diagnosis of chronic cystitis due to monilia: Cystitis (bacillary) chronic 595.2x monilial 112.2x which subterm should be selected?
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Refer to the main term "Infection" or to the main term of the organism. e.g. "Infection", "Cryptococcal = 117.5
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When an organism is specified but not indexed under the main term, for example: cryptococcal cystitis when no term for cryptococcal is located under the main term cystitis, the coder should__________?
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V01.82
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Code for contact or exposure to SARS-associated coronavirus?
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079.82
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SARS-associated coronavirus infection.
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480.3
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Pneumonia due to SARS-associated coronavirus
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1.) 066.4x 2.) Has been expanded to 5th digit to include complications.
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1.) Category used to report West Nile Virus? 2.) Expansions?
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1st = residual effect, followed by: 2nd = appropriate late effect code The infection is not coded because it is no longer present.
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How should a residual conditiondue to a previous infection or parasitic infestation be coded?
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1.) 010 - 018 2.) site or type 3.) method by which the tuberculosis was determined.
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1.) Tuberculosis is classified to categories _______? 2.) The primary axis of tuberculosis categories are the _____ or _____ of the tuberculosis? 3.) The fifth-digit subclassification of tuberculosis is used to indicate the ____________?
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False.The examples should be coded with 795.51 It is improtant to differentiate between a diagnosis of tuberculosis and a positive tuberculin skin test without a diagnosis of active tuberculosis.
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True/false? Positive results of a tuberculinskin tests including: - nonspecific reaction to tuberlculin skin test without active tuberculosis -Positive tuberculin skin test without active tuberculosis -Positive PPD -Abnormal result of Mantoux test should be interpreted as a positive diagnosis of tuberculosis and coded from the 010 - 018 category.
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Bacteremia (790.7)
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The presence of bacteria in the bloodstream after trauma or mild infection. The condition is usually transient and ordinarily clears through the actions of the body's own immune system.
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1.) Septicemia 2.) Sepsis
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1.) The term used by the ICD-9-CM to designate codes describing a systemic disease associated with pathological microorganisms or toxins in the blood. The old-school term is "Blood Poisoning". 2.) Physicians may use this term interchangeabley with ________?
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Systemic inflamatory response syndrome (SIRS)
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__________refers to the systemic response to infection, trauma/burns,or other insult (e.g. cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis.
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Sepsis
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__________ generally refers to SIRS due to infection.
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1.) fever > 101.3 - heartrate > 90 BPM - respiratory rate > 20 breaths/min - hypotension - SOB - confusion/altered MS 2.) Ask the supervisor re. assigning a code. A query to get the physician to specify might be appropriate. DO NOT IGNORE clinical picture.
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1.) The clinical picture for sepsis generally includes two of the following: 2.) if this clinical picture is present in the chart but there is no definitive diagnositc statement regarding "sepsis" or "SIRS" the coder should________ ?
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Query the physician as to whether an additional diagnosis of sepsis (095.9x) should be included.
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With a diagnosis of Septicemia (038.xx) only listed in the chart the coder should_____________?
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True (clarification from physician may be needed in some instances)
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True/False a diagnosis statement of "urosepsis" or "urinary tract infection" followed by a diagnosis of septicemia ususally indicates that the condition has progressed to septicemia, in which case the septicemia should be coded.
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1st = underlying systemic infection (e.g. 038.xx, 112.5, etc) 2nd = Sepsis (995.91)/Severe sepsis (995.92) 3rd = other localized infection (only if present)
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When sepsis or severe sepsis is the condition that, after study, necessitated the admission: How should this be coded?
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A.) 1st code principle dx. (reason for admission) followed by systemic infection code (038.xx, 112.5, or 054.5), then sepsis code (995.91/995.92) as secondary dxs. B.) The physician mus be queried for clarification to select principle dx.
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How should the following be coded? A.) sepsis/severe sepsis develops after admission? B.) The medical record is not clear regarding whether or not sepsis was present on admission?
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False. 995.9x codes are not assigned unless the term "sepsis" or "SIRS" is specifically documented and they are NEVER assigned as a principle diagnosis. (if there is a clinical picture in the chart suggesting sepsis, the physician should be queried for clarification.)
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True/False? 995.9x codes are sometimes used as a principle diagnosis to indicate a clinical picture in the chart suggesting the presence of SIRS or sepsis even when these terms are not documented by the physician.
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1.) 630 - 339 2.) 659.3x
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1.) Sepsis and septic shock associated with abortion, ectopic pregnancy, or molar pregnancy are classified to___________? 2.) If infection occurs during labor code___________?
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Code 670.0x. Do not assign 0.38, or 995.91 as systemic septicemia and sepsis(non-severe) is already covered in the 670.0x code. If septic shock is present, add code 995.92 to indicate severe sepsis and also assign codes to indicate any organ dysfunction.
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If sepsis/septic shock occurs during the puerperal period how should it be coded?
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The provider's documentation of the relationship between the infection and the procedure.
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Sepsis due to postoperative infection is coded based on______?
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1st assign complication code (e.g. 998.59 = "Other postoperative infection" or 674.3x = "Other complications of obstetrical wounds") followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Add any additional codes for organ dysfunction for cases of severe sepsis and for organism if known. Also, if septic shock occurs, assign 998.02 ("postoperative septic shock") after 995.92 ("severe sepsis")
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How should postoperative sepsis be coded?
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1st assign appropriate complication code (e.g. 999.31 = "infection due to central venous catheter" or 996.62 = infection and inflammatory reaction due to vascular device, implant, and graft") followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Add any additional codes for acute organ dysfunction for cases of severe sepsis, and for organism if known.
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How should sepsis due to vascular catheter infection be coded?
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1st code the noninfectious process (burn/injury) followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Also code for any acute organ dysfunction for cases of severe sepsis.
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How should the following be coded? A non-infectious process (burn/injury) which designated as the principle diagnosis develops infection and progresses to sepsis or severe sepsis.
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1st code the systemic (038.xx etc.) and sepsis (995.9x) codes followed by the noninfectious condition (burn/injury).
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How should the following be coded? Sepsis or severe sepsis is the principle diagnosis with the initiating event being a non-infectious process (burn/injury).
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Either may be sequenced first.
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How should the following be coded? Sepsis or severe sepsis and a non-infectious process (burn/injury) both equally meet the definition of principle diagnosis.
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True
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True/False? Only one SIRS code from 995.9x should be assigned for patients with sepsis or severe sepsis associated with trauma or other noninfectious conditions.
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1.) 038.0 2.) 038.0 + 995.91 3.) systemic (038.xx.112.5 etc.) + severe sepsis (995.92) + any associated acute organ dysfunction
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Code: 1.) Streptococcal septicemia 2.) Streptococcal sepsis 3.) severe sepsis
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systemic (038.xx.112.5 etc.) + severe sepsis (995.92) + septic shock (785.52) + any associated acute organ dysfunction
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Code: Septic shock
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Other postoperative infection (998.59) + Systemic (038.xx) + sepsis (995.91)
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Code: Sepsis due to a postoperative infection
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790.7
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Code: Bacteremia
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Other postoperative infection (998.59) + systemic (038.xx.112.5 etc.) + severe sepsis (995.92) + postoperative septic shock (998.02)
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Code: Postoperative septic shock
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Toxic shock syndrome (040.82)
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Syndrome caused by a bacterial infection and includes symptoms of: sudden onset high fever, vomiting, watery diarrhea, and myalgia, followed by hypotension and sometimes shock.
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With gram-negative bacteria sequence as: condition + responsible oganism Therefore, "Chronic pyelonephritis due to gram-negative bacteria" would be coded as: Chronic pyelonephritis (590.00) + gram-negative bacteria (0 41.85)
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Code/sequence: "Chronic pyelonephritis due to gram-negative bacteria" gram-negative bacteria =0 41.85 Chronic pyelonephritis = 590.00
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1.) The physician specifically states in the chart that an infection has become drug resistant. 2.) Condition/infection + V09.xx code (fourth digit indicates the drug to which the organism/infection has become resistant)
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1.) V codes (V09.xx) indicating infections with drug resistant organisms can only be assigned when____________? 2.) How are these codes sequenced?
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1. False. Colonization means that a patient is a carrier - the infectious organism is present in the body without necessarily causing illness. 2. A patients carrier status is indicated as with V02.5x codes.
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1.) True/False. Colonization is the same as infection. 2.) Coding to indicate that a patient is a carrier of an organism is assigned by ________?
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1.) 042 2.) False. The diagnostic statement must indicate in positive terms that the patient has an HIV related illness.
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1.) Code_________? is assigned for all types of HIV infections include diagnostic statements such as: "AIDS", "AIDS-like syndrome", "AIDS-like disease", "AIDS related conditions", "Pre-AIDS", "HIV disease" etc. 2.) True/False? This code (see above) can also be assigned when diagnostic statement indicates that infection is "probable", "possible", "likely" or "?".
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1.) V73.89 (Screening for other specified viral disease) 2.) signs, symptoms or diagnosis
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1.) When a patient with no prior diagnosis, history, signs, or symptoms of HIV requests testing of HIV status, the screening is coded as __________? 2.) When the patient shows signs or symptoms or has been diagnosed with a condition related to HIV infection the _________? should be coded rather than assigning the screening code
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1.) V65.44 (HIV counseling) 2.) 795.71
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1.) When patients make a return visit to learn the results of an HIV test, the reason for the encounter should be coded as__________? 2.) Inconclusive results of an HIV test are reported as_____?
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V08
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Positive HIV test results when the patient shows no signs or symptoms are coed as____?
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042
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When the term AIDS is used, when a patient is being treated for any HIV related illness, or when the patient is described as having any active HIV-related condition, code ____? is used.
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1.) V01.79 (Contact with or exposure to communicable diseases, other viral diseases) 2.) 795.71 (nonspecific serologic evidence of HIV) (inconclusive HIV test) 3.) HIV antibodies can cross the placenta and remain for as long as 18 months without the newborn's ever having been infected.
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1.) When a patient has had exposure to/contact with the HIV virus but has no diagnosis, signs or symptoms related to HIV assign code_________? 2.) A newborn with an HIV-positive mother testing positive on an ELISA or western blot test would be coded as ________? 3.) (see above) why is this coded as inconclusive?
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1.) 042 (Human Immunodeficiency Virus HIV) + additional codes for the related conditions. 2.) 1st code: unrelated condition (e.g. injury) as principle diagnosis, 2nd code: 042 (Human Immunodeficiency Virus HIV) + additional codes for any related conditions.
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1.) When a patient is admitted for treatment of an HIV infection or any related complication the correct coding/sequencing for this encounter is___________? 2.) When a patient with HIV infection is admitted for treatment of an entirely unrelated condition such as an injury, the correct coding/sequencing for this encounter is_______?
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1.) 647.6 (Other viral diseases) + 042 as an additional code. 2.) V08 would be assigned as an additional code.
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1.) When an obstetric patient is identified as having any HIV infection, the correct coding/sequencing is_________? 2.) When an obstetric patient tests positive for HIV but has no signs, symptoms, or history of and HIV infection, the correct coding/sequencing for is____________?
