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