HIT-205 ICD-10-CM
An exempt POA indicator is used for
- a code on the CDC list -codes that don't need to be reported -codes in chapter 7
What is a diagnosis?
-Condition -Injury -Disease -Illness
Coders can conduct a query if
-Documentation is lacking -Guidelines suggest it -Documentation conflicts
How many principles were introduced in the AHIMA Code of Ethics?
13
Find Guideline I.A.13 "Etiology/manifestation convention". This guideline indicates a coder would have a minimum of codes for a patient with etiology and manifestation conditions.
2
A category has how many digits?
3
How many purposes are served with AHIMA's Code of Ethics?
6
The neoplasm table contains ________ columns.
6
The icon or notation in the coding manual indicates code H35.12 needs ________ digits to be specific.
6. Next to code H35.12 in the tabular list, there is a red box with the "6th", indicating the code will need 6 digits for specificity.
Which is incorrect about a code of ethics?
A code of ethics guarantees ethical behavior.
If a patient is admitted due to a complication of an outpatient surgery, the coder will select
A complication code
Asking to confirm accuracy is
A query
Who approved the most recent version of the AHIMA Standards of Ethical Coding?
AHIMA House of Delegates
Section IV guidelines are called
Diagnostic coding and reporting guidelines for outpatient services
Guideline Section I.A.12.a is titled:
Excludes1
This notation means two conditions cannot occur together.
Excludes1
True or False: "Unable to determine" is the same as "possible".
False
True or False: Coders always code from the header of an operative note.
False
True or False: Coders can use the term "first-listed" diagnosis or "principal" diagnosis interchangeably because they mean the same thing.
False
True or False: If a dietician documents a patient's BMI of 38, the coder can indicate the patient as obese.
False
True or False: Seventh character digits are used throughout the coding manual. When they are used, all 7th character digits use only a 1 or 0 in the 7th position.
False
True or False: The term "and" means a code distinguishes that both conditions must exist.
False, "and" indicates either condition can be coded with the code category
True or False: A nonessential modifier is only listed with a main term in the alphabetic index.
False, a nonessential modifier can be listed with a main term or a subterm in the alphabetic index.
True or False: All ICD-10-CM diagnosis codes begin with either an alphabetic character or numeric character.
False, an ICD-10-CM diagnosis code will begin with only a letter.
True or False: A sequela is the acute illness or injury that has caused a permanent condition.
False. A sequela is the residual effect after the acute phase of an illness or injury has been terminated.
A patient is seen in the office for fever, chest pain, and cough. The provider says the patient probably has pneumonia and is sending them to the radiologist for a chest x-ray. Using Section I, II, III and IV guidelines, the coder reports
Fever, chest pain, and cough
Which of the following terms are not listed as a possible definition of a query?
Guess
If our provider documented in the medical record a definitive diagnosis,
I can code signs/symptoms if they are not part of the definitive diagnosis.
Seventh characters are discussed in guideline
I.A.5
According to HIPAA, a national data code set has been established for use. The code sets include all of the following:
ICD-10, CPT, HCPCS, NDC, CDT
If a patient is discharged from the hospital and the provider indicated the patient "likely had a kidney infection", which guideline indicates the coder can use a kidney infection diagnosis to report as the principal diagnosis for the patient's inpatient hospital stay?
II.H
History codes can be used as an additional diagnosis per Section
III
Which would be an incorrect statement regarding multiple choice queries? -The answer should only include clinically relevant options -Include an answer option for customized response -The answer should exclude clinically irrelevant options -Must include 4 answer option
Must include 4 answer option Note: There is no mandatory maximum or minimum # of dx/procedure answer option necessary to constitute a compliant multiple choice query
Diagnosis code C70.9 (Malignant neoplasm of meninges, unspecified) in the tabular list would be equivalent to this abbreviation.
NOS
If the provider doesn't include specified information to determine a diagnosis, a coder can select a code with _________.
NOS. If the information provided is not specific enough, the coder would select an "unspecified" option or NOS
Answer yes or no. Coders only code from the end of a medical record where the provider says "diagnosis".
No. Coders need to read the entire medical record to capture all diagnostic information.
The documentation by the nurse indicates a stage 1 pressure ulcer. The provider's documentation indicates a stage 2 pressure ulcer. Which is correct?
The coder should query the provider.
An adolescent examination to determine development would be coded as:
Z00.3
A patient was admitted and had surgery with a postoperative diagnosis of splenic abscess related to HIV. Which two terms, one from each of the two diagnoses indicated, would the coder reference in the alphabetic index? These two terms will each provide a code to confirm in tabular.
abscess and HIV
A coder will apply this to a condition that is present on admission.
an indicatator
A __________ is defined by ICD-10-CM as any land transport vehicle operated solely by nonmotorized pedals.
bicycle
As described in the General Coding Guidelines I.B.8, 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 (subcute) code first.
The "NOTE" included on the first page of Chapter 16 in the tabular list indicates
codes are used on newborn records only.
Guideline I.B.14 is
documentation by clinicians other than the patient's provider.
Review Guideline I.A.13 "Etiology/manifestation convention". A "use additional code" is noted with the _______ code.
etiology
n the inpatient setting, the term "principal" diagnosis is used in lieu of ______ diagnosis as referenced in the outpatient setting.
first-listed
Per the lecture information and guideline information students were required to review, a hemiparesis requires a code
indicating the dominant side.
If a coder needed to know where a patient was when they were injured, they would reference ________________ in the external cause index.
place of occurence
Z01.81 was a code provided to use for
preoperative evaluations
The diagnosis that is responsible for a patient's admission is
principal diagnosis
Review code D61.01 "Constitutional (pure) red blood cell aplasia" in the tabular list. Which word listed is the nonessential modifier?
pure
The table of drugs and chemicals has _________ columns
six
A code with a blue box next to it with "7th" and a checkmark listed inside the box means
the code will require an X placeholder.
Section II guidelines can be used
the inpatient setting
A lipoma, melanoma and myeloma are all
types of neoplasm
A code describing the activity when the injury occurred can be:
used only once on the initial encounter
A medical record contains documentation of the patient vomiting however, the provider is unable to determine why the patient is vomiting. Using this information, what diagnostic term or word would the coder reference in the ICD10CM alphabetic index to describe the diagnosis for this scenario?
vomiting
An 80-year old male with acute back pain is seen through the ED and admitted for kyphoplasty for age-related osteopathic compression fracture at vertebra T4. What 7 digit ICD-10-CM code is submitted for this encounter?
M80.08XA
Documented queries are to be retained:
According to state regulations
In the ICD-10-CM coding book the table of drugs and chemicals is found:
After the neoplasm table/ prior to the external cause index/ in the front half of the coding manual
The coding clinic is a collection of articles established by
American Hospital Association (AMA)
Per Chapter 5 coding guidelines, medical conditions due to substance use, abuse, and dependence ________ classified as substance-induced disorders.
Are not
which icon in the ICD-10-CM coding manual could potentially increase the reimbursement for a patient's stay?
MCC
To distinguish a __________ from a subcategory, the code selection includes a period (.) between the digits, for example P91.8
Category
A reason for an encounter sometimes may be called
Chief complaint
What does "CM" stand for in ICD-10-CM?
Clinical Modification
In the coding manual, Guideline I.A is called
Conventions for the ICD-10-CM
CMS - Centers for Medicare and Medicaid Services - indicates limitations for services they find reasonable and necessary called
Coverage determinations
One type of query that should not be used when clarifying documentation is
Leading
What types of queries should not be used? -Yes/no -Open Ended -Verbal -Leading
Leading
Look up in the alphabetic index of the manual: spondylitis, due to, brucellosis, lumbar region The information provided contains a manifestation code. Identify the manifestation code _____________
M49.86 Guideline I.A.13 indicates the manifestation code is included in brackets [ ]
If a coder was sitting during their certification exam, how would they know which finger name or term is used for the fourth finger?
Review the illustrations in the back of the coding manual
A health information management professional shall:
Safeguard all confidential information
Guidelines from which section(s) utilize the term "first-listed" diagnosis?
Section I and Section IV
Guideline I.B.4 is called?
Signs and Symptoms
In some situations, violations of the code of ethics would constitute unlawful conduct.
True
True or False: "Unspecified" means the provider didn't give us additional information.
True
True or False: A Chapter NOTE included prior to code selections indicates the NOTE is a reminder for every code in that chapter.
True
True or False: A code from Chapter 21 can be listed as a principal or first-listed diagnosis
True
True or False: A diagnostic test report and assessment are contents of a medical record.
True
True or False: Neoplasms can be located in the index under their histological name and in the neoplasm table.
True
True or False: There is a guideline description in the official coding guidelines directing a coder how to "locate a code in the ICD-10-CM manual".
True
True or False: A sign is an objective finding that can be measured.
True, for example a sign is a fever of 101
True or False: Parentheses are used for supplemental words that may be included in a diagnostic statement
True, parentheses are used for nonessential modifiers
True or False: Coders can select diagnosis codes for signs and/or symptoms that are not part of a disease process of a more definitive code.
True. Coders can select sign/symptoms if it is not a component of the disease process for any listed definitive diagnosis (es) for that encounter.
True or False: NEC and NOS are found in both the alphabetic index and tabular list.
True. NEC and NOS are abbreviations used in both sections.
In the tabular list of the code manual, codes in category A92 include a special notation for West Nile virus. Which notation is included?
Use additional code to specify the neurologic manifestation
Code E13.37 would need this letter ______ as a placeholder to create a specific code per the blue box icon next to the code in the tabular list.
X. Next to E13.37 in the tabular list, a blue box with "x7th" indicates a coder will need to use the letter X as a placeholder to obtain 7 digits for specificity
A POA indicator is required for newborn babies as any condition present at birth or developed in utero is considered present on admission.
Yes
