question

According to the Guidelines, which category code would you reference to report inoculations and vaccinations?

answer

Z23

question

According to the Guidelines, this category is referenced when reporting suspected exposure to a communicable disease.

answer

Z20

question

Can Z codes only be used in the outpatient setting?

answer

No

question

The I-10 code to report observation for suspected exposure to anthrax, ruled out, is

answer

Z03.810

question

When reporting the diagnosis for a patient admitted to observation status for a medical condition, assign a code for the __________ condition as the first-listed diagnosis.

answer

Medical

question

Encounter for blood typing

answer

Z01.83

question

Encounter for paternity testing

answer

Z02.81

question

Screening for diabetes mellitus

answer

Z13.1

question

Exposure to Rubella

answer

Z20.4

question

Immunization encounter

answer

Z23

question

Screening for HIV

answer

Z11.4

question

In the outpatient setting, the term _____________ diagnosis is used in lieu of ____________ diagnosis.

answer

First-Listed;Principal

question

External cause codes are never assigned as a __________ diagnosis.

answer

First-Listed

question

Codes that describe ____________________________ are acceptable for reporting purposes when a diagnosis has not been established by the provider.

answer

Signs and Symptoms

question

Z codes are located at the end of the _________________

answer

Tabular

question

For ambulatory surgery, code the _________________ for which the surgery is being performed.

answer

Diagnosis

question

In the outpatient setting, the term first-listed diagnosis is used in lieu of what diagnosis?

answer

Principal

question

What diagnosis is used when the documented condition is not confirmed in the outpatient setting?

answer

Signs and Symptoms

question

What is the first-listed diagnosis when a patient presents for outpatient surgery?

answer

Reason for surgery

question

It is important to code all the conditions or problems that are being managed during an encounter to support what?

answer

Data integrity

question

Z codes are used more frequently in what setting?

answer

Outpatient

question

What 2 code categories are used to report the first listed diagnosis for medical observation for suspected conditions and conditions ruled out?

answer

Z03 and Z04

question

Additional diagnosis codes are used to report what conditions?

answer

Coexisting

question

In what setting are uncertain diagnoses reported?

answer

Inpatient

question

What type of condition may be reported as many times as the patient receives care or treatment for?

answer

Chronic

question

What code is assigned for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or the first listed diagnosis?

answer

Z01.89, encounter for other specified special examination

question

When the primary reason for therapeutic services is chemotherapy or radiation therapy, what code category is assigned as the first listed diagnosis?

answer

Z codes

question

What code is assigned as an additional diagnosis for patient receiving preoperative evaluations?

answer

Condition that describes the reason for the surgery

question

For routine outpatient prenatal visits when no complications are present, what code category is assigned?

answer

Z34

question

When the postoperative diagnosis is different than the preoperative diagnosis at the time the diagnosis is confirmed, which diagnosis is reported?

answer

Postoperative diagnosis

question

When a patient is to have outpatient surgery and the surgery is not performed due to contraindication, the reason that the surgery was not performed is the first-listed diagnosis.

answer

FALSE

question

It is appropriate to code the postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery.

answer

TRUE

question

Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic diseases.

answer

TRUE

question

In the physician office it is acceptable to report Z codes as a first-listed diagnosis.

answer

TRUE

question

In the outpatient setting, it is unacceptable to have a sign or symptom as the first-listed diagnosis.

answer

FALSE

question

When coding an encounter for preoperative evaluation, the reason that the patient is having the surgery or procedure performed is the first-listed diagnosis.

answer

FALSE

question

In the outpatient setting, diagnoses that are documented as "probable", "suspected", "rule out", or "questionable" are reported to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reasons for the visit.

answer

TRUE

question

The first-listed diagnosis is defined as the diagnosis that is the most serious.

answer

FALSE

question

It is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80

answer

FALSE

question

It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.

answer

FALSE

question

Initial office visit for diaper rash

answer

FLD: Diaper Rash Code: L22

question

Established patient presents with dyspnea and lower extremity edema. The physician determined that the patient's symptoms were due to an exacerbation of congestive heart failure.

answer

FLD: Congestive heart failure Code: I50.9 Dyspnea and lower extremity edema are not coded as they are the symptoms of the patient's CHF exacerbation

question

Patient is a new patient who was seen for flank pain and diagnosed with a urinary tract infection, and antibiotics were prescribed. Patient has psoriasis, which is stable at this time.

answer

FLD: Urinary tract infection Code: N39.0 Other Diagnosis: Psoriasis Code: L40.9

question

Patient was admitted as an outpatient for a left arthroscopic knee procedure to repair old anterior cruciate ligament tear.

answer

FLD: Old anterior cruciate ligament tear Code: M23.8X2

question

Patient is admitted to observation for syncope. Patient has diabetes mellitus. After testing, no cardiac or other cause was found.

answer

FLD: Syncope Code: R55 Other Diagnosis: Diabetes mellitus Code: E11.9

question

Patient was admitted for pain management following biopsy of the kidney for Stage IV chronic kidney disease.

answer

FLD: Postoperative Pain Code: G89.18 Other Diagnosis: Stage 4 CKD Code: N18.4

question

Patient is seen by pulmonologist for surgical clearance for upcoming surgery. Patient has emphysema and is scheduled to have an endarterectomy for severe carotid stenosis on the right.

answer

FLD: Preoperative exam Code: Z01.811 Other Diagnosis 1: Carotid stenosis, single Code: I65.21 Other Diagnosis 2: Emphysema Code: J43.9

question

Patient had an outpatient cystoscopy. The preoperative diagnosis is hematuria. Postoperative diagnosis is hematuria due to bladder cancer.

answer

FLD: Bladder cancer Code: C67.9 The postoperative diagnosis of bladder cancer is the reason for the hematuria and more definitive diagnosis

question

Exposure to asbestos

answer

Z77.090

question

Personal history of colonic polyps

answer

Z86.010

question

Heart transplant status

answer

Z94.1

question

Established patient complaining of painful urination and frequency. Patient is a type 2 diabetic. Lab work revealed a urinary tract infection and blood glucose was within normal limits.

answer

FLD: Urinary tract infection

question

Established patient present to clinic with exacerbation of Crohn's disease. Patient's rheumatoid arthritis is stable and no medication changes were made.

answer

FLD: Crohn's disease

question

Initial office visit for sprained left knee. Patient has a history of hypertension and asthma, both stable at this time.

answer

FLD: Sprained knee

question

Initial office visit for patient requiring equal management of COPD and CHF.

answer

FLD: COPD or CHF Either could be first-listed

question

Established patient seen for cough, fever, and shortness of breath. Chest x-ray confirmed physician's diagnosis of pneumonia and patient was sent home on antibiotics.

answer

FLD: Pneumonia

question

A female patient was admitted as an outpatient for elective bilateral tubal ligation. The patient was noted to be wheezing during the nurse's assessment. She was seen by her physician and her surgery was canceled because of an exacerbation of her asthma.

answer

FLD: Admission for elective sterilization.

question

A male patient was admitted as an outpatient for transurethral prostatic resection for symptomatic benign prostatic hypertrophy.

answer

FLD: Benign prostatic hypertrophy

question

A patient was admitted as an outpatient for a cystoscopy for hematuria. The procedure was performed without complications. No abnormality or explanation for the hematuria was found.

answer

FLD: Hematuria

question

A 35-year-old female patient was admitted to observation for severe nausea and vomiting following diagnostic laparoscopy for pelvic pain.

answer

FLD: Pelvic pain

question

A male patient was admitted to observation following an endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis. Patient has a biliary duct stricture.

answer

FLD: Biliary duct stricture

question

Patient was admitted for observation because of urinary retention following a Dilation and Curettage (D&C) for post-menopausal bleeding.

answer

FLD: Post-menopausal bleeding

question

Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services take precedence over the general and disease specific guidelines.

answer

FALSE

question

Always begin the search for the correct code assignment in the Alphabetic Index.

answer

TRUE

question

When a patient presents for outpatient surgery and the surgery is canceled, report the reason why the surgery was canceled as the first listed diagnosis.

answer

FALSE

question

The codes from A00 through Z99 are always reported as first-listed diagnoses.

answer

FALSE

question

When a final diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms.

answer

TRUE

question

External Clause codes are located in the Alphabetic Index for Diseases under External Causes.

answer

FALSE

question

Report all conditions that coexist, even if they are not addressed or do not affect management/treatment during that encounter.

answer

FALSE

question

For patients receiving diagnostic services only during an encounter/visit, sequence first the reason for the encounter/visit indicated in the medical record.

answer

TRUE

question

A patient with primary lung cancer with metastasis to the spine presents for radiation treatment of the spine. The first-listed diagnosis reported is the primary lung cancer.

answer

FALSE

question

For patients receiving preoperative evaluations, sequence first a code from the subcategory Z01.81, Encounter for preprocedural examinations, followed by findings related to the preoperative evaluation.

answer

FALSE

question

Routine prenatal outpatient visits for high-risk patients are reported with a first-listed diagnosis from category O09, Supervision of high-risk pregnancy.

answer

TRUE

question

Z codes may be reported as a principal diagnosis in the hospital setting.

answer

TRUE

question

Heart transplant status code Z94.1 should not be reported with a code from subcategory T86.2, Complications of heart transplant.

answer

TRUE

question

The External Cause codes can be reported as a first-listed diagnosis.

answer

FALSE

question

When a patient is admitted to observation for a complication following outpatient surgery, report the complication as the first-listed diagnosis.

answer

FALSE

question

Established 50-year-old patient with end-stage renal disease, currently receiving dialysis, is seen for acute left upper quadrant pain.

answer

FLD: Left upper quadrant pain Code: R10.12 Other Diagnosis: End-Stage renal disease Code: N18.6 Other Diagnosis 2: Dialysis status Code: Z99.2

question

Established patient with complaints of shortness of breath. Upon examination, the physician determined she needed more aggressive treatment for her current congestive heart failure.

answer

FLD: Congestive heart failure Code: I50.9 The shortness of breath is a symptom of congestive heart failure and is not reported

question

Patient is seen for unstable angina. He has a history of arteriosclerotic coronary artery disease.

answer

FLD: Arteriosclerotic heart disease with unstable angina Code: I25.110 There is a combination code for arteriosclerotic heart disease and unstable angina. Even though the question states the patient has a history of arteriosclerotic heart disease, it means that the patient currently has coronary heart disease as the condition does not go away.

question

Patient is seen for follow-up for hypertension. He has end-stage renal disease.

answer

FLD: Hypertension with end-stage renal disease Code: I12.0 Other Diagnosis: End-stage renal disease Code: N18.6 There is a combination code for hypertension with end-stage renal disease. I12.0 assumes a casual relationship in this scenario. Under code I12.0 in the Tabular, a notation states "use additional code to identify the stage of chronic kidney disease (N18.5; N18.6)"

question

Encounter for chemotherapy for prostate cancer.

answer

FLD: Chemotherapy for neoplasm Code: Z15.11 Other Diagnosis: Prostate Cancer Code: C61 The admission for chemotherapy is always first-listed, followed by the type of neoplasm.

question

Patient with chronic obstructive pulmonary disease (COPD) is seen for an acute lower respiratory tract infection.

answer

FLD: Acute lower respiratory tract infection Code: J22 Both the COPD and infection can be reported according to the Excludes2 note, but the infection is the reason for the encounter.

question

Patient was scheduled for outpatient surgery for right inguinal hernia repair; however, he has a fever and a URI and the procedure is canceled.

answer

FLD: Inguinal hernia Code: K40.90 Other Diagnosis: Upper respiratory tract infection Code: J06.9 Other Diagnosis 2: Procedure scheduled but not performed due to contraindications Code: Z53.09 The guidelines state to code the reason for the surgery first. The fever is not reported as it is a symptom of the URI.

question

An otherwise healthy patient is seen in the clinic for exposure to tuberculosis.

answer

FLD: Exposure to tuberculosis Code: Z20.1

question

Patient presents for an outpatient chest x-ray, due to chest pain with breathing. Finding later indicated: normal x-ray.

answer

FLD: Chest pain with breathing Code: R07.1

question

Patient, with known cardiovascular disease, is seen for a follow-up visit to discuss results of a cardiac perfusion study (cardiovascular function study), which is normal.

answer

FLD: Abnormal profusion study Code: R94.39 Other Diagnosis: Cardiovascular disease Code: I25.10 The purpose of the visit is the abnormal profusion study; therefore, it is reported first, followed by the cardiovascular disease

question

Following outpatient surgery for a right bunionectomy for hallux valgus, the patient was admitted to observation due to an exacerbation of her asthma post procedure.

answer

FLD: Hallux valgus Code: M20.11 Other Diagnosis: Asthma with exacerbation Code: J45.901 The reason for the surgery is reported first, followed by the asthma with exacerbation.

question

A patient presents with a contusion to the left cheek that resulted from a fistfight, initial encounter.

answer

FLD: Contusion of the left cheek Code: S00.83XA Other Diagnosis: Fist fight Code: Y04.0XXA External cause codes are never reported as a first-listed diagnosis

question

Patient presents with a fracture of the right femur shaft due to a fall from her horse while riding, initial encounter.

answer

FLD: Fractured shaft of right femur Code: S72.301A Other Diagnosis: Falling off horse being ridden Code: V80.010A Other Diagnosis 2: Horseback riding Code: Y93.52 The external cause codes are never first-listed codes. IF the activity at the time of the event is known, it is reported after the external cause code.

question

Encounter for insulin pump titration.

answer

FLD: Encounter for insulin pump titration Code: Z46.81

question

Patient in her second trimester is seen for a regular prenatal visit. She has a history of ectopic pregnancy.

answer

FLD: Supervision in second trimester of high-risk pregnancy due to previous ectopic pregnancy Code: 009.12

question

Twin born via vaginal deliver, liveborn in the hospital.

answer

FLD: Infant, liveborn, twin, born in hospital Code: Z38.30

question

Encounter for change of nephrostomy tube.

answer

FLD: Encounter for change of nephrostomy tube Code: Z43.6

question

A patient was seen for an abrasion of the left upper arm, initial encounter.

answer

FLD: Abrasion of left upper arm Code: S40.812A

question

Established patient is seen for hypertension and a prescription is refilled for psoriasis.

answer

FLD: Hypertension Code: I10 Other Diagnosis: Psoriasis Code: L40.9 Either code could be first-placed because both problems were addressed.

question

A patient who smokes 2 packs of cigarettes per day and suffers with chronic pulmonary disease is seen in follow-up for acute bronchitis.

answer

FLD: Acute bronchitis Code: J20.9 Other Diagnoses: COPD, Cigarette smoker Codes: J44.0, F17.210 If the infectious organism is known, it would also be reported.

Z20Z Codes for Inoculations and Vaccinations

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