Coding final

How do you code a fracture that is not stated to be either a displaced fracture or a non displaced? Do you code it displaced or non displaced?

Code as displaced

What are the rules for coding uncertain diagnoses in the outpatient setting? (ex. a condition that is still uncertain at time of discharge) Should it be coded for a hospital inpatient? Does this rule apply to hospital outpatients?

Code condition as if it were established. Does not apply to OP

If no term is used to indicate whether the fracture is open or closed, do you code it, open or closed?

Code it as closed

What is the code structure for ICD-10-CM?

Codes are at least 3 characters and no more than seven. First character is always an alphabetic letter except for the letter U.

Is a biopsy a definitive procedure or a diagnostic procedure?

Diagnostic

Whats the difference between an Excludes 1 note and an Excludes 2 note?

Excludes 1 indicates that the conditions listed after it cannot ever be used at the same time as the code above the note. Excludes 2 means that two codes are applied when both conditions are present. Pt may have both conditions at the same time, one code does not include both conditions, two codes need to be applied if both conditions are present.

What does it mean when a code is in italics? What sequencing rules apply to italicized codes, whether in the Tabular list or in slanted brackets in the Alphabetic Index?

Manifestation codes. They can never be PD or by themselves

Two types of endoscopic approaches are: ______ and ______

Natural or artificial opening (ex. colonoscopy, esophagogastroduodenoscophy.) Percutaneous endoscopic -through puncture or minor incision to insert the scope to reach the site of the procedure. (ex. laparoscopy, arthroscopy)

Does the ICD-10-PCS alphabetic index always provide the complete code?

No, always refer to the tabular list

Is the coder limited to the language used by the physician in determining the root procedure? (ex. if the physician use "excision" does the coder have to code an excision or should the coder code "resection" if an entire body part was excised?)

No, they code by the definition of what is actually being performed

Should you code, as current, a condition a patient no longer has or one that doesn't affect the current hospitalization?

No, unless required by hospital policy

Can you assign an ICD-10-CM code from the alphabetic index without looking it up in the Tabular list?

No. If there are further instructions, they will be located in the tab list.

When looking up a code in an ICD-10-PCS table, can you select characters from different rows to use in a single code?

??

What does NEC mean?

Not elsewhere classifiable, directs coder to the tabular list showing an "other specified" codes description

In the alphabetic index, which would be more specific - a code found at a main term or a code found at a sub term?

A sub term. It is an extension (more specific) of the main term

Obstetrical conditions start w/ the letter "__". These codes apply to ___.

O the mother

Should you assign a separate code for the approach when a definitive procedure is performed? (ex. a laparotomy with an appendectomy.. How many codes do you need?.... One or two?

Only use one codes for the appendectomy and the laparotomy would be included in that one code as the open approach. You would not assign two codes- one for the laparotomy and and one for the appendectomy, because the root operation and the approach capture both concepts in a single code. Same principle applies to endoscopic approach.

Perinatal Conditions start w/ "___" and congenital anomalies start w/ "___". These codes apply to _____

P Q babies (usually)

_________ by a drug means the drug was given or taken improperly.

Poisoning

Principal Procedure

Procedure performed for definitive treatment rather than diagnostic or exploratory

How do you code hypertension and diseases due to hypertension?

READ P 189

What is meant by "hypertensive heart disease" or "hypertensive kidney disease" and how are combination codes used in the coding these concepts?

READ P 189

How many characters are found in ICD-10-PCS codes?

Seven

Brackets [ ]

Square brackets are used in the Tabular list to enclose synonyms, abbreviations, alternative wording, or explanatory phrases. Slanted brackets are used in the Alphabetic Index to identify manifestation codes.

________ are not coded when they occur with more severe injuries of the same site.

Superficial injuries (such as contusions and abrasions)

You cannot code both the original condition as though it were current and the sequela code for that condition on the same encounter.

TRUE

Is the PD that same as the "admitting diagnosis"?

The admitting diagnosis may just be a symptom present on admission, but by the time the patient is ready to be discharged, the physician may have determined the definitive diagnosis that caused the symptom.

If two codes are needed for a sequela (one to identify the current condition and one to identify the condition of which it is a sequela), which code is sequenced first?

The condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect

How does a coder look up the cause of the sequela in the alphabetic index?

The main term "sequela must be referenced in the alphabetic index to identify if a combination code for the sequela and underlying cause exits. in tab list, instructional note may appear under these category codes to " code first condition resulting from (sequela of)". In alpha index, following the main term "sequela" is the direction term "see also condition" to remind that other entries in the alpha index are also applicable.

How is the approach indicated in an ICD-10-PCS surgical code?

Approach is the fifth character in the code

What is the correct and incorrect use of category Z79, Long Term Drug therapy?

Assign if pt is receiving a med for extended period as prophylactic measure or as treatment of chronic condition or a disease requiring a lengthy course of treatment. DO NOT assign for med being administer for a brief period of time to treat an acute illness or injury

What are the rules for the use of ICD-10-CM Category Z04, "Encounter for examination and observation for other reasons?" Can you use these codes just because the physician documents that the patient was "admitted for observation"? Can you use these codes when a diagnosis is made? Can you use these codes when significant symptoms related to the care provided are present?

Assigned to pt's who were seen for exam and observation following various event.

What is the minimum number of characters provided by the PCS alphabetic index?

Three

Can you use more than one procedure code when a procedure is attempted w/ one approach and has to be re-started using a different approach?

Two codes, failed approach is coded as inspection and successful approach is coded accordingly

Can you use a four-character code when a five-character or longer code is available?

When a fifth, sixth, seventh character is indicated, must use to complete code.

When can symptoms, signs and abnormal findings be coded as additional codes? When should they NOT?

When they are not associated with the definitive diagnosis, they are to be coded. If they are associated, they are NOT coded.

What qualifier is used to indicate a biopsy?

X,diagnostic

Can the PD have an effect on the selection of the principal procedure? Why or why not?

Yes, because when there are two procedures that appear to be principal, the one most related to the PD should be selected.

Can you use more than one procedure when distinctive procedures are performed on the same body part (ex. biopsy of the pancreas and excision of the pancreas)?

Yes, multiple

When an infant is born in the hospital, the principal diagnosis is ______.

a Z code from category Z38

_________ means that everything concerning the drug was done correctly, but the patient still had a problem or reaction.

adverse effect

Perinatal means "____"

around birth

Traumatic fractures

injuries caused by trauma

If a diagnosis code is a sequela, the external code must also indicate ______.

late effect or sequela

Note that an expanded 7th character list for fractures includes a means to identify ______ and _____.

malunion and nonunion

Sequelae

means the original condition has resolved or healed and now the pt is left w/ some other condition that is the result of the original condition.

When looking up main terms in the ICD-10-CM Alphabetic Index, are you most likely to find the main term under the name of the condition or the site of the organ?

name of the condition

Are there age limits on congenital or perinatal conditions?

no

Does the fact that the planned treatment did not occur change the PD?

no

Pathological fractures

non-traumatic fractures that are caused by disease

What does NOS mean?

not otherwise specified, codes used when the documentation of the condition identified by the provider in the health record does not proved enough info to assign a more specific code

Place of occurrence, status, and activity codes are used ________.

only once. at the initial encounter.

Are ch 18 codes (categories R00-R99) acceptable as PDS for inpatients? If so, under what circumstances?

only when a definitive diagnosis hasn't been determined

When an "-otomy" is performed to reach the site of a procedure, this represents an _____ approach.

open

X is used as a _____.

placeholder. to make sure the 7th character is at the 7th position.

A coder must learn to recognize _____ by other terms and descriptions (such as overdose) because physicians do not usually use the exact term.

poisoning

Congenital means "______"

present at birth

External cause codes can never be ______ and can never stand alone.

principal diagnoses

When an adverse effect has occurred, the T code is not the ______, but instead a ______.

principal diagnosis, secondary diagnosis Whatever problem the patient experienced is coded as principal

The order in which the procedures were performed is not relevant in determining the _____.

principal procedure

Z codes are not ______.

procedure codes. A procedure code must be assigned in addition to the diagnosis Z code to indicate that a procedure was performed.

The first step in coding poisonings and adverse effects is to learn how to distinguish between the two, because they are _________.

sequenced differently

"R" codes are used for

symptoms, signs and abnormal findings.

Principal Diagnosis

the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.

Sometimes it takes _____ codes to code a sequela. Sometimes a ____ character extension identifies the cause of the sequela and sometimes it identifies both the cause and nature of current problem.

two, 7th

Colon :

used in the Tabular list after an incomplete term that needs one or more additional terms in order to be assigned to a particular code.

Can you code the same root operation more than once when it is repeated on different sites within the same body part value?

yes, multiple

Rules for coding multiple procedures. Do you use more than one code when the same root operations is performed on different body parts w/ distinct body part values?

yes, multiple

What guidelines exist to identify the PD is unusual circumstances? (ex. symptoms followed by contrasting or comparative diagnoses)

-Codes for symptoms, signs and ill-defined conditions are not to be used as PD when related definitive diagnosis is established -Two or more interrelated conditions, each potentially meeting the definition for PD, either condition may be sequenced first, unless the circumstances of admission, therapy provided, tab list or alpha index indicates otherwise. -Two or more diagnoses that equally meet the definition for PD, any may be sequenced first -Two or more comparative or contrasting conditions, if no further diagnosis determination can be made, either may be sequenced first. -A symptom followed by contrasting or comparative diagnoses, symptom should be sequenced first -Original treatment plan not carried out, sequence the PD as the condition which after study occasioned the admission. - Complications of surgery and other medical care, complication code is sequenced as the PD -Uncertain diagnosis, code the diagnosis as if it were certain -Admission from observation unit, Following med observation-code condition that led to hospital admission, following postop observation- apply UHDDS definition of PD as " that condition established after study to be chiefly responsible for occasioning the admission of pt to hospital for care" -Admission form outpatient surgery, if reason is complication from surgery, assign complication. if reason is unrelated to surgery, assign unrelated condition as PD

What are the five criteria for determining whether an additional diagnosis should be reported?

-clinical evaluation -therapeutic treatment -diagnostic procedure -extended length of hospital stay -increased nursing care or monitoring

What factors are used to identify significant procedures?

-is surgical in nature -carries a procedural risk -carries an anesthetic risk -requires specialized training

Definitive procedures are sequenced _____ diagnostic procedures.

before

What is the difference between an "open" fracture and a "closed" fracture?

closed-bone breaks but no puncture or open wound in skin open-bone breaks through the skin, may or may not be visible

Parentheses ( )

encloses supplementary words or explanatory info that may or may not be present in the statement of a diagnosis.

When an "-oscopy" is performed, this is always some type of ______ approach.

endoscopic

The poisoning code is the ____ listed or principle code.

first

When a patient has different degrees of burn of the same location, code only the _____ degree of burn.

highest

When a patient has multiple burns in different locations, code _______ degree burn first, then ______ degree burns.

highest, lesser