study guide icd10 – Flashcards
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The ICD-10 CM alphabetic index is composed of:
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1. Index to Diseases and Injuries 2. Table of Neoplasms 3. Table of Drugs and Chemicals 4. Index to External Causes of Injury
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Which sections of ICD-10 are referenced first when researching a diagnosis for code assignment?
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1. The Index to Diseases and Injuries 2. Table of Neoplasms 3. The Table of Drugs and Chemicals
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Refer to your alphabetic index under main term Pneumonia. Referring to the non-essential modifiers, which diagnostic terms would be coded to J18.9?
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A. Acute double pneumonia E. Septic pneumonia F. Purulent pneumonia
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The coder references the main term Cephalitis and finds the index entry " Cephalitis- see encephalitis. " This instruction to "see Encephalitis" must be followed
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True
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Which instruction is followed if there is a discrepancy between the conventions and the Official Guidelines for Coding and Reporting?
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The Conventions are followed
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What does the "X" indicate in the symbol "✓x7th"?
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B. The seventh character is required following the X
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What convention denotes that a specific diagnosis was documented but there is no corresponding code for that specific diagnosis?
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C. NEC
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A specific diagnosis is not documented. What convention is not applied because an available specific code could not be assigned?
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D. NOS
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Which convention or note tells the coder that terms listed under a code category are reported with a code fro that category?
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D. Include Note
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Which diagnostic statement(s) would likely result in the use of more than one code?
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B. Pharyngitis due to staphylococcal infection C. Influenza with pneumonia and lung abscess D. Cholecystitis with CHF
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In the alphabetix index, what indicates that an additional code must be listed?
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Slanted or italicized brackets
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A code described as NEC is more specific than a code described as NOS
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True
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What is the correct coding for chronic blod loss anemia and osteoarthritis of the hip?
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Answer: D50.0, M16.10
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What are the codes for a patient with acute viral pneumonia and dehydration?
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Answer: J12.9, E86.0
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What injury or healthcare condition is assigned an activity code?
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Fall from a horse
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A tow truck collided with a car on a highway. 30 year old driver of the tow truck was uninjured but the driver of the car suffered a femur fracture
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Answer: V44.5XXA, Y92.411
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A patient suffered extensive lacerations after being bitten by two dogs while delivering the mail. He was a postal service employee walking down sidewalk. Assign external cause code.
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...
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A fry cook at a local diner suffered third-degree burns of both of his feet after spilling hot oil on them.
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Answer: X10.2XXA, Y92.511, Y93.G3, Y99.0
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What sequence of events is the correct order for assigning external cause of injury codes?
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Cause. place. activity. status.
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In what key source document is the patient's chief complaint found?
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H&P
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Why is the admitting diagnosis helpful to know when selecting the principal diagnosis?
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The admitting diagnosis helps the coder identify the principal diagnosis
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Documentation from which of the sources below may be directly used for coding?
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Resdients progress notes Pulmonologists consultation report Discharge summary
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Procedures performed by radiologists that may be documented in the radiology section of the medical record or in the PNs are called what kind of procedure?
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Interventional radiology
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Why are the consulting physicians called into a case by the attending physician?
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The consultant provides expert advice specific to his or her specialty
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The patient is seen for acute gastroenteritis, nausea and vomitting and abdominal pain. Which diagnosis should be reported?
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Acute gastroenteritis
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The patient is seen for acute exacerbation of COPD, hemoptysis and shortness of breath. Which diagnosis is reported?
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Acute exacerbation of COPD, hemoptysis
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Reference ICD-10 book-- How many codes are assigned to diagnosis- cellulitis of left toe due to group A streptococcus?
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Two codes are assigned based on the instruction note beginning with " Use additional code..."
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What general guideline provides sequencing instructions denoted in the tabular list by the instructions " Code, if applicable, any causal condition first " and " code first "
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Assign multiple codes for a single condition
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How many codes are assigned for a condition described as acute(subacute) and chronic if the subterms in the alphabetic index are equally indented?
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Two codes
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A patient is READMITTED to the hospital after a LUMBAR puncture. Provider believes that patient's nausea, headache and photophobia are due to procedure. Patient is treated with blood-patch. How is this coded?
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Answer: G97.0
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A patient is admitted with hypertensive heart disease with CHF. Also has Type 2 Diabetes on meds, currently controlled. Code Case
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Answer: I11.0, I50.9, E11.9
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A patient has subacute lymphocytic leukemia and fatigue. How would this be coded and sequenced?
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Answer: C91.90
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Which conditions have chapter-specific sequencing guidelines?
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Sepsis. Poisoning. Obstetrics. External cause. Respiratory failure. Neoplasms.
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Which situation would result in the principal diagnosis being reported as chest pain?
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Patient with chest pain admitted to inpatient setting and left against medical advice without a definitive diagnosis.
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Which condition is a sign?
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Abdominal rigidity
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Terence was seen in the ER and admitted with status asmaticus & severe wheezing and allergic asthma. What is the coding sequence?
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Answer: J45.902
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A symptom code might be used as a principal diagnosis if the patient were transferred to another facility before a workup to determine definitive diagnosis could be completed
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Answer: True
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A patient is admitted for treatment of ACUTE DIVERTICULITIS. H&P mentions mild intermittent asthma. Friends send flowers, triggering exacerbation. Which POA indicator is assigned to J45.21?
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POA indicator N is assigned. Acute exacerbation occurred after admission. guideline pertaining to combination code is applied
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A patient previously diagnosed with ANOREXIA NERVOSA admitted with abdominal pain. After admit, patient refuses to eat. Anorexia nervosa exacerbated. Which POA indicator is assigned to F50.00?
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POA indicator Y is assigned. If no combination code available, Y is assigned regardless of when exacerbation of chronic condition occurred
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A patient admitted for lethargy and muscle aches. Test for Lyme disease ordered but patient dc'd prior to final test result being available. Result is positive. Which POA indicator is assigned?
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POA indicator N is assigned. Diagnosis " Lyme disease " was not documented at the time of admission.
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A patient admitted for emergent appendectomy undergoes lab tests after admit. Pregnancy test is positive, doctor documents "incidental pregnancy". Patient states not aware.
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POA indicator Y is assigned. Patient WAS pregnant upon admission
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A patient is admitted with shortness of breath. Results of biopsy indicate lung cancer. Following thoracotomy, patient develops acute pulmonary insufficiency. Which POA indicator?
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Assign POA indicator Y to the lung cancer and POA indicator N to the acute pulmonary insufficiency diagnosis
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Which is an acurate characteristic of the 7th character extension?
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Answer: Must always be in the 7th character field. May be preceeded by an X placeholder if the code category is five characters or fewer. May be alphanumeric.
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What are code blocks>
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Sections of code in each chapter
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Which letter in the alphabet is never used as the first character of an ICD-10 code?
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Answer: U
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What follows the third character in a four character code?
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A decimal
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Which diagnostic statement would require the coder to follow the "see also" instructional note?
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Answer: Disease, malignant
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A coder references the diagnostic term Alzheimer's disease by referencing the main term "Disease" and subterm "Alzheimer's". How should codes appear in sequence?
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Answer: G30.0, F20.80
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Which codes contain an applicable Excludes1 Note?
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Answer: A04.6, Enteritis due to Yersinia enterocolitica, A06.0, Acute amebic dysentery
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Which instructions are incorporated into the convention "Code first/ Use additional code"?
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Manifestation codes are always sequenced following the code for the etiology.
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In some cases, an ICD-10 diagnosis code can be valid with as few as three characters:
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Answer: True
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Which code can be assigned with code K08.530
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Answer: M27.52
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Which codes are examples of combination codes?
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Answer: I25.110 K50.013 E11.321 K71.51
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When reporting external cause of injury, which code category requires the use of the 7th character to indicate the type of encounter?
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Answer: V44
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In categories T36-T65, no additional external cause code is required for poisonings, toxic effects, adverse effects and underdosing codes
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Answer: True
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Which main terms appear in the ICD-10 External Causes of Injuries Index?
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Answer: Accident Activity After-effect, late
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What part of the operative report is used to assign a diagnosis code?
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The postoperative diagnosis
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When is it appropriate for the coder to use the radiologist's impression from the radiology report for assigning a diagnosis code?
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When the physician has documented a diagnosis for which the radiologist's impression provides additional specificity
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What process should be followed if the documentation in the discharge summary conflicts with other source documents?
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Physician should be queried for clarification of conflicting diagnosis
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A young man attempting to sail around world......diagnosed with vitamin C deficiency scurvy. After receiving check-up, diagnosed with heart arrhythmia caused by scurvy.What is the coding for this visit?
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I49.9, Cardiac arrhythmia, unspecified;E46.2, Sequelae of Vitamin C deficiency
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A person with alcohol dependence goes into withdrawal after the family pours all of the alcohol in the house down the kitchen drain. The final diagnosis is "alcohol dependence with withdrawal, impending delirium tremens". Patient was treated in time to prevent delirium tremens.
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Answer: F10.239, Alcohol dependence with withdrawal, unspecified
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You are the coding supervisor. Coder is attempting to assign code K22.11 twice. She complains that the computer will allow her to enter code only once. Your response?
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Refer her to the general guideline for reporting the same diagnosis code more than once
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An 82 year old is admitted with chest pain due to pneumonia versus pleurisy. AMA, patient decides to leave without workup. He is started on antibiotics and pain meds before departure. What is the principle diagnosis?
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Either pneumonia or pleurisy
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65 year old male with primary non small cell right lung cancer of right lung admitted for surgical removal of lytic metastasis bone cancer in lateral pelvic region. What is principle diagnosis?
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Answer: C79.51, Secondary malignant neoplasm of bone
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A patient represents to the outpatient surgery unit for a thyroidectomy to treat hyperthyroidism. During surgery, tachycardia due to thyrotoxic storm. Procedure was stopped and PTU was administered. Admit to ICU. Iodine therapy administered 1 hour after PTU What is principle diagnosis for Inpatient admit?
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Answer: E36.8, Other intraoperative complications of endocrine system
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A patient is admitted for shortness of breath and fever with aspiration pneumonia due to food. Also has moderate intellectual disabilities. Chronic UTI was present. Patient was treated with antibiotics and resp. therapy. What is coding sequence?
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Answer: J69.0, F71, N39.0
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Which condition would be coded as an additional diagnosis?
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A hyponatremia laboratory finding that was documented by the physician and required treatment.
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A patient is admitted for an exacerbation of Crohn's disease causing an obstruction of both duodenum and ileum. How many diagnosis codes and what POA indicator is assigned?
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Assign one code for these diagnoses, and POA indicator Y
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Wha are the characteristics of a HAC?
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Answer: High Cost Are reasonably preventable Are pre-existing
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Which of the following are exempt from the POA reporting requirements?
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Answer: Congenital malformations Acquired absence of limb Outcome of delivery Old myocardial infarction
