Billing and Coding WK 2
The ICD-10-CM Official Guidelines I.A.16 are guidelines with instructions concerning which word(s)?
"See" and "See Also"
All categories are ___ characters.
3
What is the maximum number of characters that can be used in an ICD-10-CM code?
7
What symbol is used to identify that additional characters are required?
A box with a checkmark and number
What is a systemic condition?
A condition that affects the entire body
Neoplasm Table
A list of all possible codes for benign and malignant neoplasms, in alphabetic order by anatomical location of the tumor.
__________ is/are used when a fifth, sixth, or seventh character is required yet preceding characters do not exist.
A placeholder character
Which of the following best explains the legends in the Tabular List?
Abbreviation of explanations of symbols
Which of the following is considered a combination code?
Acute respiratory failure and chronic respiratory failure
In what order would you report acute vs. chronic when both are documented?
Acute would be listed first.
Which of the following explains a hyphen?
Alert for an incomplete code
In the ICD-10-CM, where would a coder encounter italicized or slanted brackets?
Alphabetic Index
Not elsewhere classifiable may appear in the ________.
Alphabetic Index ,Tabular List
Not otherwise specified may appear in the __________.
Alphabetic Index,Tabular List
A hyphen is used in the _______ to indicate that _______ are required in code selection.
Alphabetic Index; additional characters
The ICD-10-CM is divided into the ____________Index, an alphabetic list of terms and their corresponding code, and the _____________List, a structured list of codes divided into chapters based on body system or condition.
Alphabetic, Tabular
What information is given by the notation Use additional code in the ICD-10-CM book?
An additional code may be required., This code must be listed last.
Which of the following is considered by the physician when a patient has a systemic condition?
Any and all other conditions of the patient
Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examination, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neoplasm of the Skene's gland. What is the principal diagnosis code?
C68.1
What does Code first denote in the ICD-10-CM book?
Certain conditions will require two codes and specific sequencing.
How would a coder report and sequence a differential diagnosis?
Code both diagnoses as if they were confirmed., List either diagnosis first.
Which notation is similar to Use additional code?
Code first
Which statement best describes the Table of Drugs and Chemicals section?
Codes for poison and adverse reactions to medicines
What is the purpose of having the ICD-10-CM Official Guidelines for Coding and Reporting?
Codes you report are presented in a legal manner., Codes you report support clear communication.
Name the parts listed in Section 1 of the ICD-10-CM book.
Conventions, General Guidelines, and Chapter Guidelines.
____________codes relate the whole story about why the physician provided the services, treatments, and procedures.
Diagnosis
________codes relate the whole story about why the physician provided the services, treatments, and procedures
Diagnosis
The Alphabetic Index consists of the following parts: the Index of _________and Injury, the Index of ____________of Injury, the Table of ____________, and the Table of _________and Chemicals.
Diseases, External Causes, Neoplasms, Drugs.
The ________ notation identifies codes that cannot be used together on the claim form.
Excludes 1
The ____________ _____________notation may serve as an alert that you may need an additional code for the patient's condition.
Excludes 2
Which is a warning to stop and double-check the documentation before final code selection?
Excludes 2
A type ____________ note represents "Not included here."
Excludes2
A type __________ note is a pure excludes note. It means "NOT CODED HERE!"
Exludes1
Herman Carson, a 32-year-old male, presents with a severe headache and occasional nosebleeds. Dr. Wells completed an examination recording a blood pressure reading of 180/110. Herman is hospitalized, where an ECG and echocardiogram confirm the diagnosis of malignant hypertension. What is the principal diagnosis code?
I10
Where would you find the Official Conventions section for reporting codes?
ICD-10-CM
Which of the following is true in coding based on documentation?
If it is not in writing, you can't code it.
The _______ is the section of the ICD-10-CM book that lists diagnosis by the main word or term to guide the coder to the correct page.
Index to Diseases
The _________ is the section of the ICD-10-CM book that lists diagnosis by the main word or term to guide the coder to the correct page.
Index to Diseases
Define see in the Alphabetic Index.
Information is under a different term
PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: KASSANDRA, KELLY ACCOUNT/EHR #: KASSKE001 DATE: Attending Physician: Oscar R. Prader, MD S: Pt is a 19-year-old female who has had a sore throat and cough for the past week. She states that she had a temperature of 101.5 F last night. She also admits that it is painful to swallow. No OTC medication has provided any significant relief. O: Ht 5′5″ Wt. 148 lb. R 20. T 101 F. BP 125/82. Pharynx is inspected, tonsils enlarged. There is pus noted in the posterior pharynx. Neck: supple, no nodes. Chest: clear. Heart: regular rate and rhythm without murmur. A: Acute pharyngitis P: 1. Send pt for Strep test 2. Recommend patient gargle with warm salt water and use OTC lozenges to keep throat moist 3. Rx if needed once results of Strep test come back 4. Return in two weeks for follow-up What is/are the correct diagnosis code(s)?
J02.9
In the Alphabetic Index, what does the term see instruct the coder to do?
Look at another term.
Which of the following are examples of screenings or preventive services?
Mammogram, Colonoscopy
Which of the following require the use of multiple codes?
Manifestations, Underlying conditions
A code surrounded within italicized, or slanted, brackets
Must be included
In the Alphabetic Index, where is the most common location to find the coding notation "see condition"?
Next to listing for anatomical site.
In the ICD-10-CM, what are additional terms called?
Nonessential modifiers
What is the purpose of the box with a checkmark and number symbol?
Notifies the coder that an additional character is required
In the ICD-10-CM, where would you find additional information on symbols from the legends?
Official Conventions and Additional Conventions
What would you find in the front of your code book that defines the rules and directions for accurate coding?
Official Guidelines
When there are no clear notations regarding code sequencing, where in the ICD-10-CM can you find clarification?
Official Guidelines
Where would a coder look to determine reporting order?
Official Guidelines
Which term best describes chronic conditions?
Ongoing
Which of the following is an example of an unrelated condition?
Past history
What does NOS denote?
Physician did not document details in available code descriptions.
The "x" is used as a _________ at certain codes to allow for future __________.
Placeholder, expansion
If a diagnosis has not been confirmed for an inpatient encounter, the coder must report what at the time of discharge?
Probable, possible, suspected, or rule out diagnoses
What is the purpose of the Official Conventions?
Provide directions, tips, symbols, and notations
Which of the following statements are true of the Includes notation?
Provides additional terms and diagnoses
What is the function of see also in the Alphabetic Index?
Provides an alternate main term for accuracy
Which of the following describe the purpose of the Includes notation?
Provides variations of descriptions, Provides additional terms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a __________definitive diagnosis has _____ been _________(confirmed) by the provider.
Related, not, established.
Which notation directs the coder to a different term for additional details?
See also
Refer to the ICD-10-CM Official Guidelines Section II. What is section II's title?
Selection of Principal Diagnosis
Which of the following is considered an inpatient stay?
Short-term, acute, long-term care, or psychiatric facility
Which of the following statements defines NEC?
Specifics are not described elsewhere
Where in the ICD-10-CM would you find brackets?
Tabular List
Where is the colon used?
Tabular List
Once you have found a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals, or the Index to External Cause Codes, you must go to the _____________ to confirm code selection.
Tabular List of Diseases and Injuries
The term "with" can be seen in what parts of the ICD-10-CM book?
Tabular List, Alphabetic Index
What is a preoperative evaluation?
Test performed to assess the health of a patient before surgery
Index to External Causes
The alphabetic listing of the multitude of external causes that might result in a patient's injury.
What is usually the cause for a screening test?
The calendar
Which of the following statements are true when coding test results?
The coder cannot assign a diagnosis from a test result.
Which of the following is true regarding differential diagnosis?
The physician determines signs and symptoms are equal to two diagnoses.
Which of the following is true regarding unrelated conditions?
The physician may include information that reports a condition unrelated to the encounter.
Alphabetic Index
The section of a code book showing all codes, from A to Z, by the short code descriptions.
Tabular List of Diseases and Injuries
The section of the ICD-10-CM code book listing all of the codes in alphanumeric order.
Table of Drugs and Chemicals
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.
What may the Excludes 1 notation identify about two codes?
They are contradictory to each other. They cannot coexist in the same person at the same time. They are redundant.
Why must coders read all associated code descriptions in the Tabular List?
To be in compliance with the rules and guidelines,To code only one particular encounter, To match details in physician documentation
Which of the following is an example of how parentheses are used in the ICD-10-CM?
To show additional terms or phrases included in the description of a code
Which of the following explains how italicized or slanted brackets are used?
To surround an additional code or codes that must be included with the initial code
Where would a coder find additional information on selecting a seventh character when required?
Top of the code category
What does the Code also notation indicate
Two codes may be required to describe the condition.
What do the terms "with" or "associated with" in the physician's documentation indicate?
Two conditions should be coded together.
For what type of diagnosis must you code signs and symptoms in an outpatient setting?
Unconfirmed
________ has the same meaning as Not Otherwise Specified in reporting codes.
Unspecified
Which of the following is NOT a purpose of brackets?
Use as a placeholder
When would you code for more than one diagnosis?
When the physician treats for more than one condition
Herman Carson, a 32-year-old male, presents with a severe headache and occasional nosebleeds. Dr. Wells completed an examination recording a blood pressure reading of 180/110. Herman is hospitalized, where an ECG and echocardiogram confirm the diagnosis of malignant hypertension.
Where should you begin to look up the code in the coding manual? Index of Diseases and Injuries. What is the key term? Hypertension. Do any of the following apply to the condition? None of these. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? yes If so does the Includes note help to clarify? yes Is there a Code first notation? No If so does the Code first note apply to the case study? No code first not. Is there a Code also notation? No so does the Code also note apply to the case study? No code also note Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? Yes Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? No Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? I10
Jan McKenzie, a 68-year-old female, presents today to see Dr. McLeod due to restlessness and being anxious. Jan retired 3 months ago. Dr. McLeod diagnosis Jan with problems adjusting to retirement.
Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Problem What type? Adjustment Do any of the following apply to the condition? Retirement Do any of the following apply to the condition? None of these Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code First note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? No If so does the Use additional code note apply to the case study? No Use additional code note Is there an Excludes1 notation? No If so does the Excludes1 note apply to the case study? No Excludes1 note s there an Excludes2 notation? No f so does the Excludes2 note apply to the case study? No Excludes2 note Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? Z60.0
Ralph Flower, a 27-year-old male, presents today for his annual flu vaccination.
Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Vaccination Do any of the following apply to the condition? Encounter Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? Yes If so does the Code first note apply to the case study? No Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? No If so does the Use additional code note apply to the case study? No Use additional code note Is there an Excludes1 notation? No If so does the Excludes1 note apply to the case study? No Excludes1 note Is there an Excludes2 notation? No If so does the Excludes2 note apply to the case study? No Excludes2 note Is there a symbol indicating additional characters are required? No Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? Z23
Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diagnosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA).
Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Carrier What type? Bacterial disease Do any of the following apply to the condition? Staphylococcal, methicillin resistant Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? No If so does the Use additional code note apply to the case study? No Use additional code note Is there an Excludes1 notation? No If so does the Excludes1 note apply to the case study? No Excludes1 note Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? Z22.322
Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examination, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neoplasm of the Skene's gland.
Where should you begin to look up the code in the coding manual? Table of Neoplasms What is the key term? Skene's gland Do any of the following apply to the condition? Malignant, primary Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? No If so does the Use additional code note apply to the case study? No Use additional code note Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? No If so does the Excludes2 note apply to the case study? No Excludes2 note Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? C68.1
Identify the symbol used as a placeholder character.
X
A code from the __________ section would be used as the first-listed diagnosis code followed by additional code(s) to identify the reason for an upcoming surgical procedure.
Z
Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diagnosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA). What is the principal diagnosis code?
Z22.322
Ralph Flower, a 27-year-old male, presents today for his annual flu vaccination. What is the principal diagnosis code?
Z23
Jan McKenzie, a 68-year-old female, presents today to see Dr. McLeod due to restlessness and being anxious. Jan retired 3 months ago. Dr. McLeod diagnosis Jan with problems adjusting to retirement. What is the principal diagnosis code?
Z60.0
An example of a condition is
a wound.
Acute appendicitis
a. main term: {Appendicitis, appendicitis} b. diagnosis: K35.80
Acute conjunctivitis, right:
a. main term: {Conjunctivitis, conjunctivitis} b. diagnosis: H10.31
Tuberculous cystitis:
a. main term: {Cystitis, cystitis} b. diagnosis: A18.12
Aortic endocarditis:
a. main term: {Endocarditis, endocarditis} b. diagnosis: I35.8
Adrenal fibrosis
a. main term: {Fibrosis, fibrosis} b. diagnosis: E27.8
Upper respiratory infection, chronic:
a. main term: {Infection, infection} b. diagnosis: J39.8
Systemic lupus erythematosus with lung involvement
a. main term: {Lupus, lupus} b. diagnosis: M32.13
Ulcer of lower limb, left calf with muscle necrosis
a. main term: {Ulcer, ulcer} b. diagnosis: L97.223
Acute cystitis without hematuria:
a. main term: {cystitis, Cystitis} b. diagnosis: N30.00
Fibrocystic disease of the pancreas
a. main term: {fibrocystic, Fibrocystic} b. diagnosis: E84.9
Chronic daily headache
a. main term: {headache, Headache} b. diagnosis: R51.9
Inflammation of the jaw:
a. main term: {inflammation, Inflammation} b. diagnosis: M27.2
Mobile kidney
a. main term: {mobile, Mobile} b. diagnosis: N28.89
Pulmonary necrosis
a. main term: {necrosis, Necrosis} b. diagnosis: J85.0
Lymphoid interstitial pneumonia
a. main term: {pneumonia, Pneumonia} b. diagnosis: J84.2
In the Neoplasm Table, malignant and benign neoplasms are listed by _________.
anatomical location
A ________ is used emphasize descriptors that are required to make a code valid for a diagnosis.
colon
A _________ code is two or more diagnoses for one patient on the same encounter that includes as many conditions as possible in one code.
combination
The Alphabetic Index lists items by
conditions, eponyms, and other descriptors.
If the provider documents a "borderline" diagnosis at the time of _________, the diagnosis is coded as ___________, unless the classification provides a specific entry (e.g., borderline diabetes).
discharge, confirmed
To select a code in the classification that corresponds to a diagnosis or reason for a visit documented in a medical record, __________locate the term in the Alphabetic Index, and then __________the code in the Tabular List.
first, verify
A code that has an applicable seventh character is considered _______ without the seventh character.
invalid
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______and ________side.
left, right
In the Alphabetic Index, the notation see condition instructs the coder to
locate the term that describes the health problem.
The Neoplasm Table is a section in the Alphabetic Index that lists codes for
malignant neoplasms.,benign neoplasms.
Each unique ICD-10-CM diagnosis code may be reported only _______for an encounter.
once
Turn to Hypertension in the ICD-10-CM Alphabetic Index. All of the following are listed as nonessential modifiers except
organic.
Before reporting a NOS, the coder should query the ________.
physician
The Table of Drugs and Chemicals section provides codes related to ________.
poisoning
The code that reports the most important reason for the patient's encounter is called the _______.
principal diagnosis
Diagnosis codes are to be used and ___________at their ___________number of characters available.
reported, highest
Section 1: Conventions, Coding Guidelines, and Chapter Specific Guidelines contains
rules for reporting accurate diagnosis codes.
If the same condition is described as both acute (subacute) and chronic, and ________ subentries exist in the Alphabetic Index at the _______ indentation level, code _____band sequence the _______code first.
seperate, same, both,acute.
For outpatient services, if a physician has been unable to confirm a diagnosis, a coder must report
signs, symptoms, abnormal tests, or other reasons for the encounter.
Which of the following would not be considered a systemic condition?
sprain of left coracohumeral
NEC means
the ICD-10-CM book didn't provide a code with more details.
Codes titled ____________are for use when the information in the medical record is ___________to assign a more specific code.
unspecified, insufficient
