CCS Exam Prep
When do you code HIV?
Only when it is a confirmed case. **this is an exception to the hospitral inpatient guideline Section II, H (uncertain dx); confirmation can be the provider's statements (serology/culture not necessary)
can a diagnosis of sepsis be used even if lab testing is negative or inconclusive?
Yes, but the provider should be queried
Do you code symptoms that are not an integral part of a disease process?
Yes; if they are not routinely present w/ a disease process then they should be coded
default codes
a code listed next to a main term in the alphabetic index; represents that condition that is most commonly associated with the main term; if a condition is documented in a medical record w/o additional info (acute vs chronic, etc) the default code should be assigned
What dose a dash (-) at the end of an alphabetic index entry mean?
additional characters are required
Why must tabular list always be checked and not just the alphabetic index?
alphabetic index does not always provide the full code; laterality and any 7th characters are found in the tabular list only; even when no dash is indicated
Alphabetic Index
alphabetical list of terms and their corresponding code
How should "and" be interpreted?
as and, but also as 'or' if contained in a title
How to code Sepsis?
assign the appropriate code for the underlying systemic infection. if the type of infection/organism is not specified use A41.9 (sepsis, unspecified)
how to code infection d/t MRSA that does not have a combination code?
assign the appropriate code to identify the condition along w/ B95.62 MRSA infection. do not code Z16.11 resistance to penicillin as additional dx
How should "With" be interpreted?
associated with or due to
How do you code complications of care?
base it off the provider's documentation of the relationship b/w the condition & the care/procedure **Unless otherwise instructed by the classification** there must be a cause/effect relationship
how are combination codes identified?
by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.
what is septic shock?
circulatory failure associated w/ severe sepsis - it is a type of acute organ dysfunction
How to code primary malignant neoplasms that overlap two or more contiguous (next to each other) sites?
classify to subcategory/code .8 (overlapping lesion) unless the combination is specifically indexed elsewhere
How to sequence codes for HIV-related condition admission
code B20 (HIV disease) first, then additional codes for the conditions
How to code multiple neoplasms of the same site that are not contiguous? ex: tumors in different quadrants of the same breast
code for each site should be assigned
how to code admission for patient admitted for rad/chem/immune tx, but develops complications (uncontrolled nausea, vomiting, etc)
code the encounter for chemo/rad/immno first; then code the complications
Previously diagnosed HIV-related illness
patient w/ prior dx of an HIV related illness should be coded to B20. Once they have developed this condition, B20 should be assigned on every subsequent admission/encounter. Once B20 is reported, they should never be assigned R75 or Z21.
How to code treatment of a secondary site?
if admission is b/c of a primary neoplasm w/ mets, but the treatment is directed toward the secondary site only - the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present
how to code MRSA colonization & infection?
if documentation of colonization and infection are present, code Z22.322 carrier of MRSA followed by a code for MRSA infection
how to code colonization for MSSA and MRSA w/o infection/illness/symptoms?
if documentation says "MRSA screen positive" or "MRSA nasal swab positive" this may just represent colonization if there are no associated symptoms/illness; use code Z22.322 carrier of MRSA or Z22.321 carrier of MSSA
How do you code testing/screening for HIV?
if patient is being seen to determine status use Z11.4. Use additional codes for any associated high risk behavior. If there are signs/symptoms -codes those first. Then a Counseling code Z71.7 can also be used if counseling is provided during the encounter for the test. If patient returns to be informed of the results and test is negative, use Z71.7 HIV Counseling If results are positive use HIV + guidelines
how to code treatments related to a malignancy
if the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. Exception: if the encounter/admission is solely for administration of chemotherapy, immunotherapy or radiation assign appropriate Z51.-- code as the first-listed or principal diagnosis. The diagnosis/problem for which the service is being performed is then a secondary diagnosis.
how to code treatment of a complication resulting from a surgical procedure
if treatment is directed at resolving the complication, then code the complication as principal/first
What must first be known about a neoplasm in order to code?
it must be determined fir it is benign, in-situ, malignant or of uncertain histologic behavior; if malignant any metastatic/secondary sites should also be determined
when can you report a diagnosis code more than once?
never
When do you code Z21? Asymptomatic HIV infection status
no documentation of symptoms, but is listed as HIV +, known HIV, HIV test +, etc. Do not use if AIDS is used or if being treated for or has any HIV related illness - use B20 in those cases.
how to code when there is no definitive diagnosis
report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
how to code severe sepsis?
requires at least 2 codes; -first: one for the underlying systemic infection -second: a code from subcategory R65.2 Severe sepsis if the causal organism is not docmented assign A41.9 Sepsis, unspecified. Additional code(s) for the associated acute organ dysfunction are also required.
what is a combination code?
single code used to classify - two diagnoses, or - a diagnosis w/ an associated secondary process (manifestation) - a diagnosis w/ an associated complication
Tabular List
structured list of codes divided into chapters based on body system or condition
what is urosepsis?
this is a nonspecific term that is not synonymous w/ sepsis. There is no default code for this. Provider should be queried for clarification.
What is colonization?
this means the infection (MSSA/MRSA) is present in the system, but does not necessarily cause illness
NEC - Alphabetic Index abbreviation
"Not elsewhere classifiable" This abbreviation in the Alphabetic Index represents "other specified." When a specific code is not available for a condition, the Alphabetic Index directs the coder to the "other specified" code in the Tabular List.
NEC - Tabular List
"Not elsewhere classifiable" This abbreviation in the Tabular List represents "other specified". When a specific code is not available for a condition, the Tabular List includes an NEC entry under a code to identify the code as the "other specified" code.
Code first is found where? Use additional code?
"code First" with etiology terms, "additional code" with manifestation terms
"see" & "see also"
"see" means you must go to the main term to locate correct code; 'see also' means another code may apply
When do you use multiple codes to describe a single condition?
-etiology/manifestation convention -"use additional code" note is found in tabular list; this code is secondary - "code first" notes - "code, if applicable, any causal condition first" - code may be assigned as a principle diagnosis when the causal condition is unknown or n/a. If a causal condition is known, then code for that condition should be listed first
sequencing sever sepsis - present on admission - during an encounter (not on admission)
-if present on admission & meets definition of principal diagnosis: (diagnosis must be clear, if not query provider. sometimes it can be present on admission, but not confirmed until later. always clarify ) the underlying systemic infection is first then a code from subcategory R65.2. The code from R65.2 can never be the principal diagnosis. -when it develops during an encounter (& not present on admission), underlying systemic infection & code from subcategory R65.2 should be assigned as secondary diagnoses
how to code sepsis/severe sepsis w/ a localized infection -when reason for admission is
-if reason for admission is both sepsis/severe sepsis and a localized infection (pneumonia/cellulitis, etc); first code underlying systemic infection then code the localized infection as secondary. If it is severe sepsis, code from subcategory R65.2 also. -if patient is admitted w/ localized infection & subsequently develops sepsis/severe sepsis: first code localized infection, then appropriate sepsis/severe sepsis codes
Use of codes for reporting purposes
only codes are permissible, not categories or subcategories & any applicable 7th character is required
"code also"
two codes may be required to fully describe a condition, but it does not provide sequencing direction
Excludes 1 Note exception
two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.
Inconclusive HIV serology
use R75 - inconclusive lab evidence of HIV. When lab result is inconclusive, but no definitive dx/manifestation is documented
How to code admission/encounter solely for administration of chemo/immune/radiation tx?
use code z51.0 encounter for radiation tx or z51.11 encounter for chemo or z51.12 encounter for immune tx; if they receive more than one of these during the same admission, code all in any sequence; the malignancy for which the therapy is being administered should be assigned as secondary diagnosis.
How do you code Syndromes?
use the alphabetic index; if not available assign codes for the documented manifestations
How to code management of dehydration due to malignancy?
when admission/encounter is for dehydration related to malignancy and only the dehydration is being treated (IV fluids, etc) then code dehydration first then malignancy after.
How to code an episode of care that involves surgical removal of neoplasm & adjunct txs
when an EOC involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemo/radiation tx during the same EOC - the code for the neoplasm is principal/first listed
how to code malignancy previously excised?
when malignancy has been entirely eradicated/excised from a site and no further treatment is necessary to that site use a code from category Z85 (hx of malignant neoplasm); if there is still a metastatic/invasion/extension to another site, code as a secondary malignant neoplasm and that becomes the principal diagnosis/first-listed code. Z85 code will be used as a secondary code.
how to code acute organ dysfunction that is not clearly associated w/ sepsis
when organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. In order to use the severe sepsis code the organ dysfunction must be related to the sepsis. if association in the documentation is not clear, query the provider.
how to use combination codes w/ MRSA infection?
when patient is diagnosed w/ MRSA and there is a combination code that includes the causal organism, use that code. ex: sepsis d/t MRSA, pneumonia d/t MRSA Do not use B95.62 MRSA infection as well, since the combination code includes MRSA. Do not use Z16.11 resistance to penicillin as an additional dx either
how to code postprocedural infection w/ severe sepsis & septic shock?
when the postprocedural infection causes severe sepsis which leads to septic shock, first code postprocedural infection code (T81.4, O86.0, etc) then code T81.12- (postprocedural septic shock). A code for the systemic infection should also be assigned.
how to code postprocedural infection w/ severe sepsis but no septic shock?
when the postprocedural infection causes severe sepsis, but no septic shock first code postprocedural infection code (T81.4, O86.0, etc) then code R65.20 (severe sepsis w/o septic shock). A code for the systemic infection should also be assigned.
How to code anemia associated w/ malignancy?
when the reason for admission/encounter is to treat anemia related to a malignancy and the tx is solely for the anemia - first code malignancy as principal then code for the anemia (ex: D63.0 anemia in neoplastic disease)
what is the exception to standard sequela sequencing?
where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used w/ a code for the late effect
when do you code a condition as impending or threatened?
If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened." If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.
How do you code a borderline diagnosis?
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.
How do you sequence acute/chronic conditions?
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.
Alphabetic Index consists of...
Index of Diseases & Injury, Index of External Causes of Injury, The Table of Neoplasms, and the Table of Drugs & Chemicals
Inclusion Terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
NOS
NOS "Not otherwise specified" This abbreviation is the equivalent of unspecified.
How to code zika?
Only code confirmed cases (this is an exception to Uncertain Diagnosis guideline for inpatient hospitals) - confirmation of zika can be provider's statement; lab results not necessary - if provider says "suspected" "possible" "probable" do not assign code. Instead assign a code(s) explaining reason for encounter (symptoms); ex: fever, rash, joint pain or Z20.828 contact w/ and suspected exposure to other viral communicable diseases
When to code severe sepsis?
Only if severe sepsis or an associated acute organ dysfunction is documented
How do you document infections resistant to antibiotics?
Only if the infection code does not identify drug resistance --> assign a code from category Z16, following the infection code
Steps to Locate Code
1. Locate term in Alphabetic Index 2. Verify code in Tabular List 3. Pay close attention to instructional notations in both steps 1 & 2
Excludes1 Notes
A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition
Excludes 2 Notes
A type 2 Excludes note represents "Not included here." An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate
Code ranges
A00.0 - T88.9 & Z00 - Z99.8
When do you use combination codes?
Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.
what diagnoses codes can be coded based on documentation other than the provider?
BMI, Depth of non-pressure ulcers, pressure ulcer stages, coma scale & NIH stroke scale *BMI, coma scale & NIHSS codes should only be reported as secondary diagnoses
When are [ ] brackets used?
Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes
7th characters
Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
Etiology / Manifestation - which is coded first?
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD- 10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
Tabular Lists - Explain the format & structure of categories/subcategories/codes
Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character.
Exceptions to hospital inpatient guideline Section II, H (Uncertain Diagnosis)
Code only confirmed cases of HIV, zika & flue d/t certain identified flu viruses (Category J09) and d/t other identified flu virus (Category J10).
How detailed should a code be? When can you use only 3 characters?
Codes can be 3, 4, 5, 6 or 7 characters and should be as detailed as possible. 3 character codes should only be used if not further subdivided. Codes are invalid if not fully coded, including 7th character
When to use "other" codes
Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate "other" codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code.
When to use "unspecified" codes?
Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the "other specified" code may represent both other and unspecified.
When are : Colons used?
Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category
When are ( ) parentheses used?
Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. The nonessential modifiers in the Alphabetic Index to Diseases apply to subterms following a main term except when a nonessential modifier and a subentry are mutually exclusive, the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index under the main term Enteritis, "acute" is a nonessential modifier and ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 10 of 114 "chronic" is a subentry. In this case, the nonessential modifier "acute" does not apply to the subentry "chronic".
admission/encounter due to illness related to HIV infection in pregnancy, childbirth and the puerperium
Principal dx is O98.7- (Complicating pregnancy, childbirth & puerperium) Then B20, then codes for the illness. Codes from Ch15 always take sequencing priority; if patient has Z21 (Asymp HIV), report Z21 instead of B20
how do you code symptoms of a disease process?
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
explain laterality coding
Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side
Placeholder character; give example
The "X" is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and underdosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code.
how are these codes justified?
The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis
How to sequence codes for admitted HIV + patient, but unrelated conditions (ex: traumatic injury)
The unrelated condition(s) is first, then report B20. if there are other HIV related conditions, but not the reason for the admission, report them after B20
How to sequence newly diagnosed HIV patient
This does not effect the sequencing of codes
When can you code symptoms/signs rather than diagnosis?
This is acceptable for reporting purposes when a related definitive diagnosis has not been established/confirmed by the provider; many of these can be found in Ch 18 of ICD 10 Symptoms, Signs & Abnormal Clinical & Lab findings, NEC (codes R00.00-R99)
Includes Notes
This note appears immediately under a three character code title to further define, or give examples of, the content of the category.
rule for bilateral conditions treated during separate encounters
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.
How to code malignant neoplasm of ectopic (out of place/abnormal) tissue?
code to the site of origin; ex: ectopic pancreatic malignant neoplasm involving the stomach are coded to pancreas, unspecified (C25.9) -first reference the neoplasm table in the alphabetic index. -exception: if histological term is documented, reference that term first rather than going to neoplasm table first. then determine which column in the neoplasm table is appropriate. -then consult the tabular list to verify that the correct code has been selected from the table and that a more specific code does not exist
How do you sequence sequela codes?
condition/nature of the sequela first, then sequela code second.
how to code sepsis/severe sepsis w/ a noninfectious process (condition) -when non-infectious condition is primary -when infection is primary -when both can be principal diagnosis
ex of noninfectious process: trauma, burn, serious injury, etc. when this leads to an infection that results in sepsis; the code for the noninfectious condition is principal diagnosis & is coded first. then code the resulting infection. if severe sepsis is present, one code from subcategory R65.2 should be assigned w/ any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1 systemic inflammatory response syndrome of non-infectious origin if infection is principal diagnosis; code infection first then the non-infectious condition. if both are principal diagnosis either can be assigned first only one code from category R65 is needed; do not additionally assign a code from subcategory R65.1
what are some examples of postprocedural infection codes?
ex: T80.2 infection following infusions, transfusion & therapeutic injection; T81.4 infection following a procedure; T88.0 infection following immunization or O86.0 infection of obstetric surgical wound
How to code anemia associated w/ chemo and immunotherapy?
first code anemia, then code(s) for the neoplasm then the Adverse effect (T45.1X5 adverse effect of antineoplastic and immunosuppressive drugs)
How to code anemia associated w/ radiation?
first code anemia, then code(s) for the neoplasm, then code Y84.2 (radiological procedure and radiotherapy as the cause of abnormal reaction...)
how to code sepsis d/t a postprocedural infection?
first code associated postprocedural infection code; then the specific infection; if severe sepsis then code from subcategory R65.2 w/ any additional codes for acute organ dysfunction
how to code septic shock?
first: code for systemic infection; second: R65.21 Severe sepsis w/ septic shock or T81.12 Postprocedural septic shock then any additional codes for the other acute organ dysfunctions Septic shock cannot be the principal diagnosis!
how to code sepsis w/ organ dysfunction (or multiple organ dysfunction MOD)
follow coding for severe sepsis