Medical Coding Ch 4-5 Study Guide

In the ICD-10-CM Tabular List turn to code G04.01. What notation do you find under this code?

Excludes1

The ______ notation identifies codes that cannot be used together on the same health claim form with the originally listed code.

Excludes1

A/An ____________ notation is a warning to stop and double-check the documentation so you don't report the code above the notation when a code shown in the notation may be more accurate.

Excludes2

In your ICD-10-CM turn to code L03.211 in the Tabular List. What notation is found under the code?

Excludes2

What section of the ICD-10-CM code book would provide you with a suggested code to describe how a patient was injured?

External Cause of Injuries Index

ICD-10-CM code range V00-Y99 identifies

External Causes of Morbidity.

What is the most common nail fungus infection?

Onychomycosis

In the ICD-10-CM Alphabetic Index turn to Pneumoconiosis. What punctuation(s) do you find?

Parentheses

____ is/are any agent that causes disease; a microorganism such as a bacterium or virus.

Pathogen

In order to code a diagnosis of meningitis, you have to know the specific virus or bacterium at the core of the inflammation. This can typically be found in the ______ report.

Pathology

The code description that states "diseases classified elsewhere" means that:

the condition has its own code within this code set.

Refer to the ICD-10-CM Official Guidelines Section I. How many parts does Section I have?

3

Coding for septic shock will require:

3 codes.

Primary immunodeficiency disorders include all of the following except:

AIDS.

Refer to the ICD-10-CM Official Guidelines Section IV.C. This guideline concerns:

Accurate reporting of ICD-10-CM diagnosis codes

______ is severe; serious.

Acute

The Table of Drugs and Chemicals' first column shows a list of substances. Moving to the right, the sixth column identifies which of the following?

Adverse effect

Tuberculosis is transmitted by:

Air

Outpatient coders cannot assign a diagnosis code for a diagnosis documented as:

All of these

AMR stands for:

Antimicrobial Resistance.

When there are no symptoms or manifestations this is known as:

Asymptomatic.

Which of the following are named by their shape?

Bacteria

_______ will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description.

Brackets

The Neoplasm Table is set up as a seven-column table organized by the information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is found in column four?

Ca in situ

____ identifies that pneumonia has developed in a patient who has not recently been in the hospital or another health care facility.

Community-acquired pneumonia

_____ is of long duration; continuing over an extended period of time.

Chronic

The ______ notation is a reminder that you are going to need another code to identify the underlying disease that caused the diagnosed condition.

Code first

The correct sequence for coding SIRS is:

Code for the underlying condition, code the SIRS, code the acute organ dysfunction.

George Honker is diagnosed with acute hepatitis B without delta-agent with hepatic coma. The main term is _____; the correct diagnosis code is ______.

Hepatitis, B16.2

According to the ICD-10-CM Official Guidelines, section ____ corresponds to Selection of Principal Diagnosis.

II

The ______ notation provides you with additional terms and diagnoses that are included in the above code (this code's description).

Includes

_____ is the reaction of tissues to infection or injury; characterized by pain, swelling, and erythema.

Inflammation

Debbie Simmons is diagnosed with influenza with respiratory manifestations. The main term is _____; the correct diagnosis code is ______.

Influenza, J11.1

Which of the following punctuation is found in the Alphabetic Index?

Italicized brackets and parentheses

What is the first step in looking up an ICD-10-CM diagnosis code?

Look up the main term in the Alphabetic Index.

A breakout section of the Alphabetic Index listing the suggested codes for benign and malignant neoplasms is known as the:

Neoplasm Table.

_______ report a code for HIV infection or illness without a specific physician diagnostic statement-a confirmed diagnosis.

Never

ICD-10-CM code range J00-J99 identifies the Diseases of the

Respiratory System.

A physical reaction, such as fever and chills, to an unspecified pathogen is a diagnosis referred to by the acronym

SIRS

The rules for coding uncertain diagnoses for patients of an inpatient facility are different from those for outpatients. You will find the guideline in which section?

Section II.H

Refer to the ICD-10-CM Official Guidelines I.C.1.d.2.a which states: _______generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.

Septic shock

In the ICD-10-CM Alphabetic Index turn to Disease>Alzheimer's. What punctuation(s) do you find?

Slanted Brackets

There are times when a fifth, sixth, or seventh character is required, yet there are no fourth, fifth, or sixth characters. In these cases, ICD-10-CM uses a placeholder character, the letter ____, so the following characters will fall into their correct locations.

X

When an infection or virus spreads throughout the entire body it is known as:

Systemic.

The section of the ICD-10-CM code book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction is known as the:

Table of Drugs and Chemicals.

Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find that code in the

Tabular List of Diseases and Injuries.

The diagnosis of sepsis must include:

a specified pathogen.

An infection can spread through:

all of these

Throughout the ICD-10-CM code book you will find which of the following to help guide you to the most accurate code for a patient encounter?

all of these

The Tabular List section of the ICD-10-CM book lists every code and its complete description in ______ order by code.

alphanumeric

The presence of unknown bacteria in the blood may be diagnosed as:

bacteremia

Tetanus is an infection of the nervous system and is caused by the entry of _______ into the body through a break in the skin.

bacteria

Staphylococcus aureus is what type of infection?

bacterial

A _____ located to the left of a code in the Tabular List is a symbol that notifies you that an additional character is required.

box with a checkmark and number

What are hookworms, pinworms, and tapeworms examples of?

parasites

The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should code:

chest congestion.

If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. These codes are known as:

combination codes.

When the physician indicates that the patient's signs and symptoms may closely lead to two different diagnoses and using the word versus or or between two diagnostic statements this is known as a/an:

differential diagnosis.

Dysentery is transmitted by:

drinking contaminated water.

Exposure due to some diseases, such as influenza, can be transmitted by coughing, spitting, talking, and sneezing. This type of exposure is known as:

droplet exposure.

Malaria, a disease spread by mosquitoes, is an example of a:

parasitic infestation.

Mushrooms, yeast, and mold are edible forms of:

fungi

If two (or more) diagnoses are of equal severity, then report them in order of anatomical site— ______.

head to toe

A patient complains of dizziness. The physician states that she has hypertension. The coder should assign a code for:

hypertension.

Signs of Cellulitis include all of the following except:

hypertension.

A _____ is used in the Alphabetic Index to indicate that additional characters are required.

hyphen

The diagnosis of severe sepsis must include:

identification of the underlying infection and which organ failed.

The coder _____ report(s) a code directly from the Alphabetic Index without checking it in the Tabular List.

never

When a patient acquires a condition that develops as a result of being in a health care facility it is known as a(n) _____ condition.

nosocomial

NEC stands for:

not elsewhere classifiable.

The diagnosis of severe sepsis must include a(n):

organ dysfunction

The word or phrase _____ means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn't have in any of the other codes in the category.

other specified

Lice and mites are examples of:

parasites

All of the following are types of pneumonia except:

phlegm.

The condition, after study, that is the primary, or main, reason for the admission of a patient to the hospital for care; the condition that requires the largest amount of hospital resources for care is known as the:

principal diagnosis

Signs and symptoms of an existence of infection include all except a(n):

rash.

Janie was visiting her uncle on his farm and drank untreated milk. Janie began to vomit and has diarrhea and abdominal pain. Janie's uncle took her to the doctor who diagnosed Janie with salmonella poisoning. The coder should assign code(s) for:

salmonella.

According to the ICD-10-CM Official Guidelines, I.C.21.c.5: ______ is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease.

screening

A condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision making for any other condition is known as a:

systemic condition.

Exposure due to physical interaction with blood, bodily fluids, nonintact skin, and mucous membranes can enable a long list of bloodborne pathogens to make their way from one person to another. This type of exposure is known as:

touch exposure.

One disease that affects or encourages another condition is known as a:

underlying condition.

Refer to the ICD-10-CM Official guidelines I.C.1.a.2.b which states: If a patient with HIV disease is admitted for an _____ condition, the code for the ______ condition should be the principal diagnosis.

unrelated, unrelated

Chickenpox is a:

viral infection.

Which of the following can lay dormant for long periods of time?

viruses

Which of the following embed themselves in host cells and can be difficult to isolate?

viruses