Diagnostic coding chapter 5

Syndromes

Go to syndrome first. In ICD 9 don't ever code borderline.

Guidelines four sections

1. Conventions, general coding guidelines, and chapter specific guidelines. 2) Selection of principal diagnosis, 3) Reporting additional diagnoses, 4) Diagnostic coding and reporting for outpatient services.

Organizations

AHA, AHIMA, CMS, NCHS. CMS developed it.

BMI and Pressure Ulcer

Depth. Always go to guidelines first!

When the admission is for treatment of a complication resulting fromm surgery or other medical care, the complication code is sequenced as the secondary diagnosis.

Falase

The alpha index provides the full code

False

The principal diagnosis is defined as "that condition established after the study to be chiefly responsible for occasioning the outpatient visit of the patient to the hospital for care

False because it says outpatient

Laterality

Right, left or is bilateral. If no bilateral code is provided and it is bilateral, code for both separately.

In the physcian's office setting, the definition of principal diagnosis does not apply

TRUE

A sequala is the residual effect after the acute phase of an illness or injury has terminated.

True

A three digit code is to be used only if it is not further subdivided.

True

Codes for symptoms, signs and ill defined conditins from chapter 18 are not to be used as principal diagnosis when a related definitive diangosis has been established

True

Each unique ICD10 CM code may be reported only once for an encounter

True

If the same condition is described as both acute and chronic and if separate subentries exist in the alpha index at the same indentation level, cod both, with the acute code first.

True

Dash

additional characters are required.

acute and chronic

code acute first

Impending or threatened conditions

coder must ask, did the condition actually occur? If yes, then code as a confirmed diagnosis. Can't be used in a physician's office.

In the outpatient setting the term_____ is used in lieu of principal diagnosis

first listed diagnosis or chief complaint.

sequela

late effects--complication codes which full describe a condition. Must read guidelines

Code first

means go to something else first. Underlying condition must be coded first.

Use additional code

normally found at the infectious disease code, indicating a need for an organism code as a secondary code.

When a symptom is followed by contrasting/comparative diagnosis, the symptom code is sequenced first

true