ICD-10-CM
Main term in alphabetical index
1st place you go to locate the code for the patient's disease or condition
World Health Organization (WHO)
A global organization that works to improve health care and promote health services.
Diagnoses
CPT codes allow reporting of what?
ICD-10-CM
Designed for the classification of patient sickness (morbidity) and death (mortality) information
Z66
Do not resuscitate status
Z09
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm such as; fracture, after psychotherapy, after surgery, etc.
Z04
Encountered for examination and observation when there has been an event or suspected event and the physician wants to examine the patient; car accident/rape/child abuse *only used if alleged-once determine the code may need to change
NOT CODED HERE
Excludes1 notes means __
Inpatient procedures only
ICD-10-CM codes are used for reporting of what?
Volume 1 and 2
ICD-10-CM replaces which part(s) of ICD-9-CM?
Inpatient procedures only
ICD-10-PCS codes are used for reporting of what?
Medical procedures
ICD-10-PCS replaces which part(s) of ICD-9-CM?
Z30-Z39
Persons encountering health services in circumstances related to reproduction
Z20-Z28
Persons with potential health hazards related to communicable diseases; if the patient has been immunized
Z18
Retained foreign body fragments
False
T/F: A Z code should be used when a patient has a past history of a disease and still has the disease even though this is not the specific reason for the encounter.
True
T/F: A teenager visits his physician for a checkup in order to participate in high school football. Z codes are used to code his reason for the visit even though there isn't a health diagnosis.
True
T/F: Additional codes may be used to further describe the patient's condition. These codes are listed after the first-listed diagnosis code.
True
T/F: An important use of Z codes is to report when a healthy individual sees a physician to receive a vaccine.
True
T/F: ICD-10-CM codes can be used for outpatient surgery even if that surgery occurs in a hospital outpatient facility.
False
T/F: Mr. Roberts must have outpatient surgery but then cancels it. The first-listed diagnosis should be the "surgery cancellation" code.
False
T/F: The Z code should only be the first-listed diagnosis if a specific complication coded with a Z code is the reason for the visit.
False
T/F: Z codes and codes for external causes are the same.
True
T/F: Z codes can be used to report a patient's exposure to a communicable disease even if the patient does not have any symptoms or signs.
True
T/F: Z codes help tell that patient's entire medical history as it relates to the patient encounter for the first-listed diagnosis
chief complaint (CC)
When a patient comes into an outpatient facility or is admitted to the hospital there must be a specific reason, which is called a __
Z34
code category that is for a routine outpatient prenatal visit when the patient has no complications
Z77-Z79
code that allows reporting of a personal or family history related to the patient encounter; exposure to toxic mold, order to be restrained
Z68
code used for Body Mass Index (BMI)
Z67
code used for blood type
Z49-Z53
codes allow reporting of a variety of specific reasons for a visit to the doctor or medical facility such as; preventative removal of breast, ear piercing, male circumcision, and palliative care
z03
codes are to be used when the person does not have a diagnosis but is suspected of having some abnormal condition
Z59
codes that allow reporting of a patient's circumstances related to housing and economic circumstances; homeless, difficulty with landlord, poverty
Z60-65
codes that allow reporting of various types of social and psychosocial circumstances; situations not diagnosis that can impact the diagnosis or treatment of patient; socially excluded patient, difficulty adjusting to retirement or recent death of spouse
Z00 codes
codes that are used to report encounters for general examinations without a chief complaint, or a suspected or previously reported diagnosis
z11
codes that report screening for infectious diseases
z55-z57
codes that report various health hazards related to a patient's education, literacy level, or employment; underachiever, illiterate, unemployed, etc
z08
codes used for patients with a malignant neoplasm and the doctor wants to have periodic follow-up exams
Z55-Z66
encounter of patient's socioeconomic or psychosocial circumstances can impact diagnosis or treatment condition
Mortality
frequency of death or death rate
Z14 & Z15
genetic carrier and genetic susceptibility to disease codes
Morbidity
incidence of a specific notifiable disease
status codes
indicate that a patient is either a carrier of a disease or has a sequela or residual or past disease condition *only used for additional information
Choice List
indicates the possible target system codes that when combined is one valid scenario
Tabular list
is a numerical list of all of the codes, organizes codes by blocks and categories, provides important coding information at the beginning of each chapter, and is divided into 21 chapters.
Tabular List
listing of all the codes in numerical order
DNT
medical order written by a doctor instructing the health care providers NOT to do a cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating
Etilogy
nature of the disease process (cause)
Alphabetical index
organizes the main terms in bold type with subterms indented under the main term, should be the starting point for looking up a code, and includes main terms that represent diseases, conditions, nouns, and adjectives to make it easier to locate a code.
Coexisting conditions
other conditions in addition to the chief complaint
z codes
represent REASONS for encounters
always the main reason the patient saw the physician
the first-listed diagnosis is __
First-listed diagnosis
the main diagnosis or symptoms and signs for which the patient sees the physician
Scenario
the number of variations of diagnosis combinations included in the source system code
General Equivalency Mapping (GEM)
tool that can be used to convert data from ICD-9-CM to ICD-10-PCS and vice versa; crosswalks since they provide information that links codes between the two
Z016
used to report infections that are resistant to drugs; describe the specific drug to which the microorganism is resistant