Coding #3

For those categories for which an unspecified code is not provided, the "other specified" code may represent what?

"other" and "unspecified"

When manifestation codes do not have "in disease classified elsewhere" there is ______ code note at the etiology code and a ______ code note at the manifestation code.

"use additional Code" and "code first" FYI the etiology/manifestation rules for sequencing apply

What does the word "with" or "in" should be interpreted to mean?

"associated with" or "due to"

What can the word "and" mean?

And can mean either "and" or "or" when it appears in the title.

Which excludes note represents "Not Included here"

Excludes 2

This note appears immediately under a three-character code title to further define or give examples of the content of a category?

Includes Note

What is a list of terms included under some codes?

Inclusion terms

What terms are the conditions for which that code is to be used?

Inclusion terms

What is a code listed next to a main term in the index?

default code

While the patient may be seen by a new provider over the course of tx for an injury, assignment of the 7th character is based on whether the PT is undergoing active tx and NOT what?

whether the provider is seeing the pt for the first time

The ICD-10-CM utilizes a placeholder character ______. This is used as a placeholder at certain codes to allow for future expansion

x

What note instructs that two codes may be required to fully describe a condition, but this note does note provide sequencing direction.

"code also" FYI: The sequencing depends on the circumstances of encounter

What kind of codes are for when the information in medical records provides detail for which a specific code does not exist?

"other" or "other specified"

What following a main term in the index instructs that there is another main term that me also be referenced that may provide additional index entries that may be useful?

"see also" FYI it is not necessary to follow the "see also" note when the original main term provides the necessary code e.g., virus, viral

What following a main term in the Index indicates that another term should be referenced?

"see"

Codes titled ______ are for use where the information in the medical record is insufficient to assign a more specific code

"unspecified"

What does the alphabetic index consist of? (There are 4)

1. Index of disease and injury 2. Index of external causes of injury 3. The table of neoplasm 4. The table of drugs/chemical

In the ICD-10-CM Tabular List first character is a _____ except for ____, which is reserved for further expansion, and the second character is always a _____.

1. letter 2. U 3. number

What are 5 examples of subsequent encounter situations?

1. med adjustment 2. other after care, including drsg change. 3. f/u visits following tx of the injury or condition 4. Aftercare of injuries 5. Fx code except with the pt delayed seeking tx resulting in a malunion or nonunion

Per the coding clinic, examples of active tx include:

1. surgical tx 2. er visit 3. encounter and eval 4. cont tx by same or different physician

All categories are _______ characters these categories that have no further subdivision is equal to a _______.

3 and Code

When are [ ] "brackets" used?

A. Tabular List to enclose synonyms B. Alphabetic Index for manifestation codes

What does Alphabetic Index mean?

Alphabetic list term and corresponding code

What does Tabular List mean?

Chronological list of codes divided into chapters based on body systems or condition.

What code represents the condition that is most commonly associated with the main term or the unspecified code for the condition.

Default Code If the condition is documented in a medical record with out any additional info, such as acute or chronic this code should be assigned K37.

Which exclude note is a pure exclude note which means :NOT CODED HERE"

Excludes 1

Which excludes note means that the code excluded should never be used at the same time as the code above this note?

Excludes 1

Which note is used when two conditions cannot occur together such as congenital for versus an acquired form of the same condition?

Excludes 1 Ex: cannot code 2 types of DM together

Which note indicates that the condition excluded is not part of the condition represented by the code but the patient may have both conditions at the same time?

Excludes 2

When are parenthesis ( ) used?

In both to enclose supplementary words that may be present or about in the statement of a disease or procedure without affecting the code to which it is assigned

In Alphabetic Index both conditions are listed together with etiology code first followed by the manifestation code in the what?

Italicized brackets. This code is always to be sequenced immediately after the etiology

What is equivalent of "unspecified" and is only used when information in med record is insufficient to a more specific code?

NOS (not otherwise specified)

* Consider whether you have more specific information before selecting a what?

NOS code

When a specific code is not available for a condition, the Alphabetic Index directs the coder to what code in the Tabular List?

Other Specified

The assignment of a dx code is based on what?

The providers diagnostic statement that the condition exists. FYI- The providers statement that the patient has a particular condition is sufficient

For malunion and nonunion of fx what is assigned in the appropriate 7th character for initial encounter

When the pt delayed tx

NEC ( not elsewhere classified ) means "other specified" and is found in Alphabetic Index and Tabular list when ICD-10-CM system does not provide what?

a more specific code for a condition

*Cont of IVATB or Oral ATB for post op infection is coded with a 7th character for initial encounter. Is this active or not active?

active

The 7th character for "initial encounter" should be assigned as long as the patient is undergoing what for a condition

active treatment

Certain ICD-10-CM categories have applicable 7th characters, which are required for ___ within the category, or as the notes in the Tabular List instruct

all codes

A dash following the category or subcategory in the alphabetic index neoplasm table, and tabular list, indicates what?

an incomplete code -eg., D24-and L89.5-

What are not based on clinical criteria used by the provider to establish the dx?

code assignment

For reporting purposes, only____ are permissible, not categories or subcategories and any applicable _____ character is required

codes #7

What are used in the Tabular list after an incomplete term that needs one or more of the modifier following it to make it assignable to a given category?

colon :

"use additional code" note at the what code? "code first" note at the what code?

etiology code and manifestation code FYI these instructional notes indicates the proper sequencing order of the codes, etiology followed by manifestation.

The ICD-10-CM has a coding convention that requires the underlying condition sequenced____ followed by the manifestation

first

"The diseases classified elsewhere" codes are never permitted to be used as what?

first listed or principal dx codes

The ICD-10-CM has two types of exclude notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are what of each other?

independent

What is assigned as long as the pt is still receiving active tx for the condition described by the code?

initial encounter

*The first character of ICD-10-CM code is always a _____ (except ____) which is reserved for future expansion. The second letter is always _____. The remaining characters may be either ____ or _____.

letter (alpha), Except U, number (numeric), alpha, Neumeric, NOT alpha

The terms the parenthesis are referred to as what?

non essential modifiers

The nonessential modifiers in the alphabetic Index to disease apply to subterms (also known as subentries) following a main term, except when?

nonessential modifier & a subentry are mutually exclusive then subentry takes precedence

* What should happen if there is a question as to whether a condition listed under the term "with" or "in" is related?

physician should be queried

If a code that requires a 7th character is less than 6 characters a ______ must be assigned for all the empty characters.

placeholders

In the alphabetic index under the main term Enteritis "acute" is a non essential modifier and the "chronic" is a what?

subentry FYI in this case, nonessential modifier "acute" does note apply to the subentry "chronic"

Home Health care is typically a what as is post acute care in rehab facility

subsequent encounter

Inclusion terms may be _____ of the code title or in the case of "other specified" codes the terms are a list of the various conditions assigned to that code

synonyms FYI the inclusion terms are not necessarily exhaustive

"In diseases classified elsewhere" must be used in conjunction with what code?

underlying condition code and must be listed following the underlying condition code

When an Excludes 2 note appears under the code, it is acceptable to use what together, when appropriate?

use both code and the excluded code