Diagnosis Coding Module 10

clinical testing not inconclusive

Abnormal Findings (R70-R94) Abnormal findings are not coded unless the physician indicates their ________ significance Abnormal findings may be the reason for additional _________ to be performed Some findings may be "incidental" to the patient's current condition and usually _____ coded Category R92 includes findings that are considered ____________ and not necessarily abnormal

Alphabetic

Abnormal Findings (R70-R94) Nonspecific abnormal findings form laboratory, x-ray, pathologic and other diagnostic tests. These nonspecific findings may be referred to as signs or clinical signs __________ Index entries to locate these codes include: Abnormal, abnormality, abnormalities Findings, abnormal without diagnosis Decreased Elevation High or Low or Positive

common

Abnormal Tumor Markers (R97) Testing has become _________ practice for elevation in tumor markers, for example testing for: Tumor-associated antigens (TAA) Tumor-specific antigens (TSA) Carcinoembryonic antigen (CEA) Prostate specific antigen

laboratory conclusions

Abnormal findings include objective measurements documented in ____________ reports Abnormal findings of imaging and other studies are the ___________ written by radiologists and other physicians based on review of images or data collected during diagnostic studies

biochemical

Abnormal tumor markers are objective measurements of __________ substances that are indicative of the presence of tumors. Tumor markers are used to screen, diagnose, assess progress, follow up response to treatment and monitor for recurrence of neoplasia TAA, TSA, CEA, PSA are common markers

consciousness delirium

Altered Mental Status, Unspecified (R41.82) May be a symptom of different illnesses Should not be confused with altered level of ____________ (R40.-) or _________(R41.0) After workup, if a specific cause of the altered mental status is known, that condition should be coded, and the symptom code should not be used. See the Excludes1 note under code R41.82

principal first secondary

Assign an appropriate code(s) from categories Q00-Q99, Congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented. A malformation/deformation/or chromosomal abnormality may be the ________/_______-listed diagnosis on a record or a __________diagnosis.

every

Category R99 is provided to describe ill-defined or unknown cause of mortality It is only used when a patient arrives at facility as dead on arrival (DOA) and pronounced dead by examining physician Code is not used for ________ patient who expires

numbers

Chromosomal Defects Abnormal __________ of chromosomes or defects in specific fragments of the chromosomes Each disorder is associated with a characteristic pattern of defects The more common chromosomal conditions include: Down syndrome associated with the presence of a third number 21 chromosome. Also known as Trisomy 21 Edward's syndrome is associated with the presence of a third number 18 chromosome. Also known as Trisomy 18 Patau's syndrome is associated with the presence of a third number 13 chromosome. Also known as Trisomy 13

history principal followed

Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal _________ code should be used to identify the history of the malformation or deformity. Although present at birth, malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the physician, it is appropriate to assign a code from codes Q00-Q99.For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the ___________ diagnosis, ________ by any congenital anomaly codes, Q00- Q99.

systems General

Codes from R00-R49 that describe symptoms and signs involving certain body __________, such as circulatory, respiratory and digestive __________ symptoms and signs (R50-R69) include symptoms and signs that could be explained by various body systems

chapters

Coding Instructional Notes for ICD-10-CM Chapter 18 Many of the blocks and categories have "Excludes1" notes that direct the coder to locate diagnosis codes that appear in other _________ of ICD-10-CM Guidelines that clarify code usage are also found under specific codes

before available problems

Coding Instructional Notes for ICD-10-CM Chapter 18 Conditions included in this chapter are (4) Cases referred elsewhere for investigation or treatment ________ the diagnosis was made (5) Cases in which a more precise diagnosis was not __________ for any other reason (6) Certain symptoms, for which supplementary information is provided, that represent important ___________ in medical care in their own right

diagnosis transient return

Coding Instructional Notes for ICD-10-CM Chapter 18 Conditions included in this chapter are 1- Cases for which no more specific __________ can be made even after all the facts bearing on the case have been investigated 2- Signs and symptoms existing at the time of the initial encounter that proved to be _________ and whose cases could not be determined 3- Provisional diagnosis in a patient who failed to ________ for further investigation of care

seventh

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 Coma Scale One code from each subcategory (R40.21, R40.22 and R40.23) is needed to complete the scale The __________ character extension indicates when the scale was recorded and it should match for all 3 codes 0-unspecified time 1-in the field (EMT or ambulance) 2-at arrival to emergency department 3-at hospital admission 4 to 24 hours or more after hospital admission

after

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 Coma Scale Subcategory R40.2, Coma, incorporates the Glasgow Coma Scale (R40.211-R40.236) codes These codes are used in conjunction with traumatic brain injury or sequelae of cerebrovascular disease codes These codes are sequenced ________ the diagnosis codes

Alphabetic

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 _____________ Index entries used to locate the symptoms and sign codes include Abnormal, abnormalities Elevated, elevation Findings, abnormal, inconclusive, without diagnosis Positive

not

Coding of Papanicolaou Test (Pap Smear) Findings R87.6-R87.9, Abnormal cytological, histological and other abnormal findings in specimens from female genital organs. Bethesda System of Cytologic Examination These codes are _____ intended to be used to report a confirmed dysplasis, CIN or carcinoma in situ conditions

only

Coma Scale (R40.2) At a minimum, the initial score documented on presentation to the facility is coded Hospital can choose to capture multiple coma scale scores Some hospitals and physicians may only document one total coma score. One code R40.24, total score, may be the ______ coma score code assigned in this situation

symptom

Combination codes that include symptoms ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the __________.

not

Death NOS Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival. It does _____ represent the discharge disposition of death.

bilateral unilateral stenosis

Digestive System Defects Orofacial and gastrointestinal defects Cleft lip and cleft palate or combination of both Cleft lip codes are subdivided to identify bilateral, median or unilateral forms Cleft palate codes are identified as hard palate or soft palate When both exist, codes identify which palate is involved and whether cleft lip is _________ or __________ type Pyloric __________ is narrowing of the outlet between the stomach and the small intestine; identified soon after birth

body type congenital

ICD-10-CM Chapter 17: Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) Chapter organized by _______ system Organized into subcategories to identify the _______ of condition Codes provide specificity according to the anatomic site and the combination of __________ conditions

otherwise specified

ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00-R99  Categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point equally to two or more diseases or to two or more systems of the body All categories could be designated "not __________ ___________"

neurologic documented

Functional quadriplegia (code R53.2) is the lack of ability to use one's limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of __________ quadriplegia. It should only be assigned if functional quadriplegia is specifically __________ in the medical record.

one

General Symptoms and Signs (R50-R69) Classifies symptoms that are not related to _____ body system Examples include: Two codes exist for febrile seizures: complex and simple Category R52, Pain, unspecified, as a symptom code for generalized pain or pain without specificity of site R68.12, Fussy infant or R68.11, Excessive crying of infant

not unexplained

Ill-define and Unknown Causes of Mortality (R99) Category includes death or unexplained death and other conditions that are unspecified causes of mortality These codes are _____ used when a more definitive diagnosis is available May be used on a patient's record when the patient is brought to the hospital and is dead on arrival (DOA) but the reason for the death is unknown. However, this code is not used to report all deaths. Code is only used when the death is __________ and no cause is documented

additional manifestations physical intellectual

Instructions are included to direct the coder when ___________ codes are required, for example, use additional code for associated paraplegia or associated glaucoma When a congenital condition does not have a unique code assignment, the coder should assign additional code(s) for any _____________ that may be present Review the note under category Q87 For chromosomal abnormalities, a note appears to use additional codes to identify any associate _________ condition or the degree of ____________ disabilities that are present

clubfoot

Musculoskeletal Defects Relatively common and range from minor problems to more serious conditions. The most common musculoskeletal anomaly is __________ that includes Varus deformities or inward turning of the feet Valgus deformities or outward turning of the feet Talipes cavus or increased arch of foot Talipes calcaneous or equinus or an abnormal upward or downward misalignment

manifestation

NCHS has published chapter-specific guidelines for Chapter 17 in the ICD-10-CM Official Guidelines for Coding and Reporting Assign chapter 17 code when abnormality is documented Code may be the principal/first-listed or a secondary diagnosis code When condition does not have unique code, assign additional code(s) for any ____________ present

not life

NCHS has published chapter-specific guidelines for Chapter 17 in the ICD-10-CM Official Guidelines for Coding and Reporting (continued) Manifestations that are an inherent component of the anomaly should not be coded separately Additional codes are assigned for manifestations that are _____ an inherent component of an anomaly Codes can be used throughout the ______ of the patient Personal history codes used when no longer present

investigated future together

Repeated falls Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being ____________. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for _________ falls. When appropriate, both codes R29.6 and Z91.81 may be assigned __________.

other

Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in ________ chapters of the classification

outpatient inpatient additional

Symptom and sign categories are frequently use in __________ settings to indicate that the patient has a physical complaint for which a definitive diagnosis has not been established. Symptom code might be used for an _________ diagnosis when a reason for the complaint cannot be determined. Symptom codes may be used as __________ codes with an established diagnosis to describe the complete story of the patient's illness if the symptom is not an integral or usual part of the disease

coded

Symptoms and Signs by Body System (R00-R69) Conditions that are not routinely associated with a disease process rule: Additional signs and symptoms that are not routinely associated with a disease process should be __________ when present For example, patient has metastases to brain and is in a comatose state: the coma is coded as it is significant condition that is not routinely associated with brain metastases

additional

Symptoms and Signs by Body System (R00-R69) Conditions that are routinely associated with a disease process rule: Symptoms and signs that are routinely associated with the disease process should not be assigned as __________ codes unless otherwise instructed by the classification For example: nausea and vomiting are not coded with gastroenteritis as these are symptoms of the gastroenteritis

after match presentation total

The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced _______ the diagnosis code(s). These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should ________ for all three codes. At a minimum, report the initial score documented on ___________ at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24, Glasgow coma scale, total score, when only the _______ score is documented in the medical record and not the individual score(s).

underlying condition followed addition queried

The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the __________ _________, such as an injury, should be assigned, __________by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in _________ to code R65.11. If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be _________.

diagnosis

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures and ill-defined conditions regarding which no __________ classifiable elsewhere is recorded Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters. Categories in this chapter are symptoms and signs that point perhaps equally to two or more diseases or body systems

diagnosis before classification

Use of a symptom code with a definitive diagnosis code Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that __________, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced ________ the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the _____________.

established

Use of symptom codes Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been ___________ (confirmed) by the provider

manifestations

When a malformation/deformation/or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any ____________ that may be present.

following congenital

When an infant is born with a congenital anomaly, an appropriate code from Chapter 17 of ICD-10-CM should be used on the infant's record __________ the code from category Z38 to identify the place of birth and type of delivery When an infant is transferred to another hospital for care of the congenital condition, the principal diagnosis at the second hospital would be the ___________ condition and the Z38 code is not assigned

not

When the code assignment specifically identifies the malformation/deformation/or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are ______ an inherent component.

Central Nervous

_________ __________ System Defects Involve the brain, spinal cord and associated tissue Include neural tube defects (anencephaly, spina bifida and encephalocele), microcephalous and hydrocephalus Common CNS defect is spina bifida which is a defective closure of the vertebral column Most types coded to category Q05, with 4th digit subcategories to describe the site with presence or absence of hydrocephalus

Congenital Chromosome

__________ anomaly Malformation or deformation that is present at or existing from the time of birth ____________ abnormality Irregularity in the number or structure of chromosomes that may alter the course of the development of the embryo

Respiratory

___________ System Defects Involve the lungs, trachea, and nose Less common group of defects Lung hypoplasia or dysplasia is a failure to develop or underdevelopment of one or both lungs Respiratory anomalies require immediate medical and surgical care to correct it so that the infant regains adequate respiratory function

Symptom Sign

___________ is any subjective evidence of disease reported by the patient to the physician _______ is objective evidence of a disease observed by a physician

Genitourinary

____________ Tract Defects Affects both males and female; some are relatively minor and fairly common defects that can be repaired by surgery. Some of these defects are: Mullerian anomalies of the uterus Bladder exstrophy Epispadias and hypospadias Obstructive genitourinary defects Renal agenesis or hypoplasia Cystic or polycystitic kidney disease

Cardiovascular

_____________ System Defects Involve the heart and circulatory system Most common group of birth defects in infants Surgical procedures repair defects and restore circulation to as normal as possible More commonly occur are patent ductus arteriosus, atrial septal defect, ventricular septal defect and pulmonary artery anomalies