ICD-10 Study Guide
New feature found in the ICD-10-CM Index not found in ICD-9-CM:
Is the use of a dash (-) at the end of an index entry to indicate that additional characters are required
ICD-10 CM & PCS are closed classification systems:
They provide one and only one place to classify each condition and procedure
fragmentation
breaking solid matter in a body part into pieces
Unlike ICD-9-CM, the ICD-10-PCS Index does not generally provide:
a complete code (with a few exceptions), but it will guide the coder to the correct Table byspecifying the first three or four characters of the code
carcinoma
cancer of epithelial cells of connective tissue
sarcoma
cancer of supportive tissue, such as blood vessels, bones, cartilage, and muscles
leukemia
cancer of the blood-forming organs
lymphoma
cancer of the lymph nodes and immune system
malignant neoplasms
cancerous growth
Certified Professional Coder, Hospital Based (CPC-H)
certification for coders offered by the American Academy of Professional Coders
Certified Medical Assistant (CMA)
certification for the medical assisting profession
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: gives all codes
a unique definition
appendix
a wormlike structure that is found at the blind end of the cecum
bypass
altering the route of passage of the contents of a tubular body part
gastric ulcer
an ulcer that occurs in the stomach
duodenal ulcer
an ulcer that occurs in the upper part of the small intestine
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: allows new procedures
and technologies to be incorporated easily
alimentary canal
another name for the digestive system
Character 5 in the Medical and Surgical Section provides definitions for the ____________.
approach
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: provides detailed descriptions of methodology and
approach for procedures
Administrative Simplification
aspect of the Health Insurance Portability and Accountability Act of 1996 that developed standards for the electronic exchange of health-care data by administrative and financial transactions
American Association of Medical Assistants (AAMA)
association that represents individuals trained in performing routine administrative and clinical jobs that keep medical offices and clinics running efficiently and smoothly
occlusion
complete closure of an office or lumen of a tubular body part, such as a vessel
occlusion
complete closure of an orifice or lumen of a tubular body part, such as a vessel
ICD-10-CM consists of
diagnosis codes
cardiomyopathy
diseases of the heart muscle
hirsutism
excessive hair growth
old myocardial infarction
identifies a history of a heart attack in the past
When coding an ileostomy, the Body Part is
ileum
lymphadenitis
inflammation of the lymph nodes
heart attack
occurs when there is inadequate blood supply to a section or sections of the heart; also known as myocardial infarction
Assign the PCS code values using
the Index and Tables
coding
the assignment of numerical or alphanumerical characters to specify diagnostic and procedural phrases
occlusion of cerebral and precerebral arteries
the blocking of arteries
epidermis
the outermost layer of the skin
pheresis
the separation of blood products
Who develops Sepsis?
Anyone can develop sepsis, but it's most common and most dangerous in older adults or those with weakened immune systems. Early treatment of sepsis, usually with antibiotics and large amounts of intravenous fluids, improves chances for survival.
For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code
For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1, Postprocedural hypoinsulinemia. Assign a code from category E13 and a code from subcategory Z90.41-, Acquired absence of pancreas, as additional codes.
N - Release
Freeing of a body part from an abnormal physical constraint by cutting or by use of force. Some of the restraining tissue may be taken out but none of the body part is taken out. Examples: Adhesiolysis, carpal tunnel release
For old or healed myocardial infarctions not requiring further care, code _____
For old or healed myocardial infarctions not requiring further care,--- code I25.2, Old myocardial infarction, may be assigned.
For patients who routinely use insulin, code ____, Long-term (current) use of insulin, should also be assigned. Code _____ should not be assigned if insulin is given temporarily to bring a patient's blood sugar under control during an encounter.
For patients who routinely use insulin, code Z79.4, Long-term (current) use of insulin, should also be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a patient's blood sugar under control during an encounter.
Embedded meaning of characters:
ICD-9-CM volume 3: No ICD-10-PCS: Yes, multi-axial structure, with each code character having the same meaning within the specific procedure section and across procedure sections to the extent possible
Alphanumeric or numeric:
ICD-9-CM volume 3: Numeric ICD-10-PCS: Alphanumeric
Excludes notes:
ICD-9-CM volume 3: Yes ICD-10-PCS: No
Includes notes:
ICD-9-CM volume 3: Yes ICD-10-PCS: No
Decimal point:
ICD-9-CM volume 3: yes ICD-10-PCS: No
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence. The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis.
How to code ICd-10 for Acute organ dysfunction that is not clearly associated with the sepsis
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.
How to code diagnosis Sepsis with organ dysfunction
If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis.
If a patient is admitted for an HIV-related condition, the principal diagnosis should be ___, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all _____________ conditions.
If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions.
If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for _____ stage documented.
If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented.
If a patient is being seen to determine his/her HIV status, use code ____, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk behavior.
If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk behavior.
What is the primary diagnosis If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury)?
If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions.
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the____should be sequenced before the _______.
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.
If a patient with signs or symptoms is being seen for HIV testing, code_____. An additional counseling code ____, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.
If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms. An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. What is the only exception?
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.-- code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
If the type of diabetes mellitus is not documented in the medical record the default is
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus.
Excludes1
Instructs that the code excluded should never be coded together with the code under which the excludes1 note appears. Recent Coding Clinic instructions will modify this.
Excludes2
Instructs that the condition excluded is coded elsewhere, but may be coded in conjunction with the code under which the excludes1 note appears.
G - Fusion
Joining together portions of an articular body part, rendering the articular body part immobile. The body part is joined together by fixation device, bone graft, or other means. Examples: Spinal fusion, ankle arthrodesis
S - Reposition
Moving to its normal location or other suitable location all or a portion of a body part. The body part is moved to a new location from an abnormal location, or from a normal location where it is not functions correctly. The body part may or may not be cut out of off to be moved to the new location. Example: reposition of undescended testicle, fracture reduction
0 - Alteration
Modifying the natural anatomic structure of a body part without affecting the function of the body part. Purpose to improve appearance Examples: Face lift, breast augmentation
"See also"
The coder should follow this instruction if the entries under consideration are not exactly what is being coded.
cerebral hemorrhage
bleeding in the brain or layers of brain lining
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Provides detailed descriptions for
body parts
melanocytes
cells that produce dark pigment
Certified Professional Coder (CPC)
certification for the medical assisting profession
Each Section of the manual designates how each _________ of the code is used within that Section
character
ICD-10-PCS codes are constructed of seven __________ or positions, each with a distinct purpose and meaning.
characters
bile
chemical secreted by the liver to help in digestion
hormones
chemical substances produced by the body to keep organs and tissues functioning properly
diabetes mellitus
chronic problem resulting from problems with the pancreas
Improvement and major modifications to ICD-9-CM: creation of combination diagnoses/symptom
codes t reduce the number of codes needed to fully describe a condition
performance
completely taking over a physiological function by extracorporeal means
cancer
condition that is characterized by malignant neoplasm
Cushing's syndrome
condition that results from the excessive and chronic production of cortisol by the adrenal cortex or by the administration of glucocorticoids in large doses for a period of several weeks or longer
endocrine system
consists of several different internal groups of glands and structures that produce or secrete hormones
To be diagnosed with septic shock, you must.........
To be diagnosed with septic shock, you must have the signs and symptoms of severe sepsis — plus extremely low blood pressure that doesn't adequately respond to simple fluid replacement.
Type 1 diabetes
Type 1 diabetes occurs because the insulin-producing cells (called beta cells) of the pancreas are damaged. People with Type 1 diabetes produce little or no insulin, so sugar cannot get into the body's cells for use as energy. This causes blood sugar levels to rise. People with Type 1 diabetes MUST use insulin injections to control their blood sugar. The damage to the insulin-producing cells in Type 1 diabetes occurs over a period of years. However, the symptoms of Type 1 diabetes might occur over a period of days to weeks. Type 1 is the most common form of diabetes in people younger than 20 years old, but it can occur at any age. Also called juvenile diabetes.
Hypertension, Uncontrolled
Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories I10-I15, Hypertensive diseases.
Excludes notes ICD-9-CM
Yes
Laterality in ICD-10-CM:
Yes
Dummy placeholders ICD-10-CM:
Yes: "x"
The signs and symptoms of Severe sepsis are
Your diagnosis will be upgraded to severe sepsis if you also exhibit at least one of the following signs and symptoms, which indicate an organ may be failing: Significantly decreased urine output Abrupt change in mental status Decrease in platelet count Difficulty breathing Abnormal heart pumping function Abdominal pain Septic shock
ICD-10 Code ___, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive
Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology. Do not use this code if the term "AIDS" is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.
lipoma
a benign neoplasm of adipose tissue
portal vein thrombosis
a blood clot in the main vein of the liver
cancerous growths
a condition in which cancer cells multiply; also called a malignant neoplasm
goiter
a condition in which the thyroid becomes enlarged even though hormone secretions fall within normal limits
heart failure
a decreased ability of the heart to pump a sufficient amount of blood to the body's tissue
heart
a muscular organ that pumps blood throughout the body
direct inguinal hernia
a protrusion in the groin area
bedsores
a sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as decubitus ulcer, pressure ulcer, or pressure sore
cellulitis
a type of infection that develops in the layers of the skin
Crohn's disease
a form of inflammatory bowel disease that can cause the thickening and scarring of the abdominal wall; also known as regional enteritis
hair
a form of protection used by the body to keep foreign material from entering through the skin
Centers for Medicare and Medicaid Services (CMS)
a government agency responsible for maintaining the procedure codes ICD-CM, which are found in volume 3 of the ICD system
abscess
a localized collection of pus and indicates tissue destruction
change
taking out or taking off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane
assistance
taking over a portion of a physiological function by extracorporeal means
point dash
tells the coder that the code contains a list of options at a level of specificity past the three-character category
approach
the way in which the surgeon, physician, or provider performs a procedure
Excludes
these notes are used to signify that the conditions listed are not assigned to the category pt block of category codes
Code First
this note instructs the coder to select a code to represent the etiology that caused the manifestation
Code Also
this note is used in ICD-10-CM to instruct the coder that two codes may be needed to fully code a diagnostic phrase
See
this note is used in the Alphabetical Index ICD-10-CM and instructs the coder to cross-reference the term or diagnosis that follows the notation
Includes
this note is used to define and/or give examples of the content of a category of ICD-10-Cm or of a block of category codes
Excludes 1
this note mend that the diagnostic terms listed are not coded to the category or subcategory
See Also
this note refers the coder to another location in the alphabetic index when the initial listing does not contain all the necessary information to accurately select a code
shock wave therapy
treatment by shock waves
ultrasound therapy
treatment by ultrasound
ultraviolet light therapy
treatment by ultraviolet light
phototherapy
treatment of a vein
neoplasms of unspecified behavior
tumors in which the morphology and behavior of the neoplasm is not specified in the patient's medical record
Assign value Z when there is no ___________.
device
The ________ key is a crosswalk from device brand names and common names to the PCS Device Description.
device
Improvement and major modifications to ICD-9-CM: expansion of
diabetes and injury codes
Final residual category is provided for:
diagnoses not stated specifically enough to permit more precise classification; occasionally, these two residual groups are combined into one code
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Includes no
diagnostic information in the code
varicose veins
dilated superficial veins of the legs
cerebrovascular accident (CVA)
disruption in the normal blood supply to the brain; also called a stroke
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: ensures that code expansions
do not disrupt the structure of the system
transient hypertension
elevated blood pressure but not identified as chronic hypertension
ICD-10-PCS ________ the use of eponyms.
eliminates
brackets
enclose synonyms, alternative wording, abbreviations, or explanatory phrases
hemorrhoids
enlarged veins in or near the anus
percutaneous
entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure
percutaneous endoscopic
entry, by puncture or minor incision, of instrumentation through the skin our mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure
ICD-10-PCS does NOT include
eponyms
destruction
eradicating all or a portion of a body part
ulcers
erosions of the skin in which tissue becomes inflamed and then lost
_____________ means that the structure of the code set allows new procedures to be easily incorporated.
expandability
dilation
expanding an orifice or the lumen of a tubular body part
decompression
extracorporeal elimination of undissolved gas from body fluids
electromagnetic therapy
extracorporeal treatment by electromagnetic rays
melanoma
fast-growing cancer of melanin-producing cells
carbuncles
furuncles cluster and form a puslike sac
Improvement and major modifications to ICD-9-CM: More space to accommodate
future expansions (alphanumeric structure)
sebaceous glands
glands of the skin that produce an oily secretion to condition the skin
ICD-10-PCS Tables are composed of:
grids identifying the valid combinations of characters that make up a procedure code
alopecia
hair loss
nails
hardened cells of the epidermis
secondary hypertension
high arterial blood pressure due to another disease, such as vascular disease
urticaria
hives
ICD-10-PCS is used for billing of
hospital inpatient services
healed myocardial infarction
identifies a history of a heart attack in the past
Improvement and major modifications to ICD-9-CM: Greater specificity
in code assignment
Improvement and major modifications to ICD-9-CM: Inclusion of trimester information
in pregnancy codes
appendicitis
inflammation of the appendix
diverticulitis
inflammation of the diverticula
cholecystitis
inflammation of the gallbladder
myocarditis
inflammation of the heart muscle
Main term entries for procedures in the ICD-10-PCS can be
located in alphabetical order within the Indes
map
locating the route of passage of electrical impulses and/or the functional area in a body part
hypotension
low blood pressure
creation
making a new structure that does not physically take the place of a body part
alteration
modifying the anatomical structure of a body part without affecting its function
glucose
needed for the cells to properly supply energy for the body's metabolic functions
neoplasms of uncertain behavior
neoplasms in which cells are not histologically confirmed even after pathological investigation
carcinoma in situ (CIS)
neoplastic cell that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, non infiltrating carcinoma, noninvasive carcinoma, and pervasive carcinoma
in situ neoplasms
neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also known as carcinoma in situ; ca in situ, or CIS
noninfiltrating carcinoma
neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also known as transitional cell carcinoma, carcinoma in situ, noninvasive carcinoma, and preinvasive carcinoma
The ICD-10-PCS is a classification of:
operations and procedures developed for use in the U.S.; not part of the WHO classification
American Academy of Professional Coders (AAPC)
organization founded in an effort to elevate the standards of medical coding
American Health Information Management (AHIMA)
organization that represents the health information professionals who manage, organize, process, and manipulate patient data
Hospital resources include all of the following EXCEPT
physicians
Improvement and major modifications to ICD-9-CM: New categories for
postprocedural disorders
diverticula
pouches or sacs in the lining of the intestine that cause diverticulitis if the sacs become inflamed
extraction
pulling or stripping out or off all or a portion of a body part
insertion
putting in a nonbiological appliance that monitors, assists, performs, or presents a physiological function but does not physically take the place of a body part
malignant primary
refers to the originating site of a malignant tumor
malignant secondary
refers to the site of tumor metastasis
biopsy
removal of tissue or cells for pathological examination
accessory organs
secondary organs
division
separating, without taking out, a body part
pressure sores
sore resulting from continuous pressure in an area that eventually limits or stop circulation and oxygen flow to an area; also known as de cubits ulcer, pressure ulcer, or bedsore
pressure ulcers
sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as decubitus ulcer, pressure sore, or bedsore
Both exclude notes indicate:
that excluded codes are independent of each other
Bc ICD-10-PCS codes are used only by hospitals for inpatient procedures,
the ICD-10-PCS cods would not be used in outpatient transactions or by physicians
decubitus ulcers
sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as pressure sore, pressure ulcer, or bedsore
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: is very
specific
method
specifies how the external access location was entered when a procedure is performed on an internal body part
Improvement and major modifications to ICD-9-CM: The addition of laterality -
specifying which organ or part of the body is involved when the location could be on the right, the left, or bilateral
______________ means that the code set includes definitions of the terminology it uses and eacah term must have only one meaning.
standardized terminology
hyperparathyroidism
the abnormal or insufficient secretion of parathyroid hormone by the parathyroid glands, caused by a primary parathyroid dysfunction or elevated serum calcium level
hypoparathyroidism
the abnormal or insufficient secretion of parathyroid hormone by the parathyroid glands, caused by a primary parathyroid dysfunction or elevated serum calcium level
adult onset diabetes
the body is unable to produce sufficient amounts of insulin within the pancreas; patient might be insulin dependent or not; also known as Type II diabetes
thrombolytic therapy
the intravenous administration of thrombolytic agents, often completed to open the coronary artery occlusion and to restore blood flow to the cardiac tissue
fusion
the joining of portions of an articular boy part, rendering the part immobile
hypothermia
the lowering of body temperature
ICD-10 Procedure Coding System (ICD-10-PCS)
the most recent version of the ICD coding system set up to replace volume 3 of the ICD-9-CM system
diastolic blood pressure
the pressure on the arterial walls during relaxation of the heart muscle
systolic blood pressure
the pressure on the arterial walls during the heart muscle contraction
hyperthermia
the raising of body temperature
gastroesophageal reflux disease (GERD)
the reflux of the stomach acid and pepsin into the esophagus, causing inflammation
restoration
the return or the attempt to return a physiological function to its natural state by extracorporeal means
instrumentation
the specialized equipment used to perform a procedure on an internal body part
duodenum
the start of the small intestine at the end of the stomach
extirpation
the taking or cutting out of solid matter from a body part
dermis
the thick layer of tissue located directly below the epidermis
control
stopping, or attempting to stop, postprocedural bleeding
gallbladder
stores bile secreted by the liver
Expandability:
structure of ICD-10-PCS should allow for the easy incorporation of unique codes as new procedures are developed
esophagus
structure that connects the throat to the stomach
encapsulated
surrounded by a capsule; confined to an area with a capsule; not able to metastasize
hypothyroidism
the thyroid is not operating as efficiently as it could be due to a deficiency of hormone secretion
hyperthyroidism
the thyroid is producing excessive amounts of thyroid hormones
drainage
taking or letting out fluids and/or gases from a body part
tumors
the uncontrolled abnormal growth of cells; also called a neoplasm
neoplasms
uncontrolled abnormal growth of cells; also called tumors
veins
vessels that carry deoxygenated blood from the body back to the heart
arteries
vessels that carry oxygen-rich blood from the heart to the body
inspection
visually and/or manually exploring a body part
ICD-10-PCS is a replacement for
volume 3 of ICD-9-CM, but bears little resemblance
lack of specificity of the ICD-9-CM creates problems such as:
•inability to collect accurate data on new technology, •increased requirements for submission of documentation to support clams, •lack of quality data to support health outcomes and •less accurate reimbursement
Sepsis due to a postprocedural infection ICD-10 Guidelines
(a) Documentation of causal relationship As with all postprocedural complications, code assignment is based on the provider's documentation of the relationship between the infection and the procedure.
The guiding principles followed in the development of ICD-10-PCS are:
1. Diagnostic info is not included in procedure descript. 2. "not otherwise specified (NOS) options included 3. not elsewhere classified (NEC) options provided on a limited basis 4. All possible procedures are defined regardless of the frequency of occurrence. If a procedure could be performed, a code was created
Chronic kidney disease, stage ___ requiring chronic dialysis, should be coded to ___ within an additional code to identify dialysis status ___.
1. Stage 5 2. N18.6 End stage renal disease 3. Z99.2
ICD-10-CM consists of:
21 chapters resulting in nearly sixty-nine thousand codes
Minimum number of digits/characters ICD-9-CM for a cholecystectomy:
3
Minimum number of digits/characters in ICD-10 and ICD-9:
3 in both
Minimum number of digits/characters ICD-10-PCS for a cholecystectomy:
7
the 16 sections of ICD-10-PCS represent nearly:
72,000 codes
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to..... For multiple neoplasms of the same site that are not contiguous ....
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.
when a patient who has suffered an Acute myocardial infarction has a new Acute myocardial infarction within the 4 week time frame of the initial Acute myocardial infarction then code_____
A code from category I22, Subsequent ST elevation (STEMI) and non ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
A malignant neoplasm of a transplanted organ should be coded as
A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.
Which of the following should be sequenced before any other procedures?
A procedure required to care for a complication
HCFA (now CMS) funded a preliminary design project for:
A replacement for volume 3 of the ICD-9-CM
Improvement and major modifications to ICD-9-CM: Inclusion of codes for
Advances in medicine that have occurred since the last revision care conditions, problems related to lifestyle, and the results of screening tests
Alphanumeric vs. numeric ICD-10-CM:
Alphanumeric, with all codes starting with an alpha character and some codes with alpha seventh-character value
1 - Bypass
Altering the route of passage of the contents of a tubular body part. Examples: Coronary artery bypass, colostomy formation
Classification system is:
An arrangement of elements into groups according to established criteria
An underdose of insulin due to an insulin pump failure should be assigned to a code from
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code T38.3X6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned.
The fifth character in the Medical and Surgical section defines the ________ or technique used to reach the procedure site.
Approach
Assign code ___, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension.
Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. Assign code O13.-, Gestational [pregnancy-induced] hypertension without significant proteinuria, or O14.-, Pre-eclampsia, for transient hypertension of pregnancy.
ICD-10-CM/PCS codes may not be reported:
Before the compliance date
Character 4 defines the ________ or specific anatomical site where the physician performed the procedure.
Body Part
P, Upper Bones is a ____________ value with the skeletal system.
Body System
The Medical and Surgical Section has 31 possible values for the _________.
Body System
F - Fragmentation
Breaking solid matter ina body part into pieces. Physical frce (eg manual, ultrasonic) applied directly or indirectly throuh intervening body parts are used to break the solid matter into pieces. The solid matter may be abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out, but are sliminated or absorbed through normal biological functions. Examples: Extracorporeal shockwave lithotripsy, transurethral lithotripsy
ICD-10 was released:
By WHO in 1993
Ileostomy is an example of what Root Operation?
Bypass
HCFA is now:
CMS
Open 0
CUTTING THROUGH the skin or mucous membrane and any other body layers necessary to EXPOSE THE SITE of the procedure. Ex: open CABG, open endarterectomy
Central pain syndrome chronic pain syndrome "chronic pain," are all the same thing. True or False
Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term "chronic pain," and therefore codes should only be used when the provider has specifically documented this condition.
ICd-10 Guideline: Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from .......
Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required.
What subcategory is chronic pain classified to? Define chronic pain.
Chronic pain is classified to subcategory G89.2. There is no time frame defining when pain becomes chronic pain. The provider's documentation should be used to guide use of these codes.
one of the more significant changes for ICD-10-CM is:
Clarification of the exclusion notes
When should Malignant (primary) neoplasm, unspecified, equating to Cancer, unspecified be utilized?
Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.
Code ____ is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor.
Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic.
What kind of HIV cases are coded?
Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the provider's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.
L - Occlusion
Completely closing an orifice or lumen of a tubular body part. The orifice can be natural or artificially created. Examples: fallopian tube ligation, ligation of inferior vena cava
________ means there should be a unique code for every procedure that is significantly different in body part, approach, or method.
Completeness
W - Revision
Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device. Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin. Examples: Adjustment of position of pacemaker lead, recementing of hip prothesis
8 - Division
Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part. All or a portion of the body part is separated into two or more portions. Examples: Spinal cordotomy, osteotomy
6 - Detachment
Cutting off all or part of the upper or lower extremities. The body part value is the site of the detachment, with a qualifier to further specify the level where the extremity was detached. Examples: Below knee amputation, disarticulation of shoulder
B - Excision
Cutting out of off, without replacement, a portion of a body part. The qualifier "diagnostic" is used to identify procedures that are biopsies. Examples: Partial nephrectomy, liver biopsy
T - Resection
Cutting out or off, without replacement, all of a body part. Examples: total nephrectomy, total lobectomy of the lung
What is diabetes?
Diabetes mellitus is a disease that prevents your body from properly using the energy from the food you eat.
When does diabetes occur?
Diabetes occurs when either: The pancreas (an organ behind your stomach) produces little insulin or no insulin at all. (Insulin is a naturally occurring hormone produced by the beta cells of the pancreas that helps the body use sugar for energy.) -Or- The pancreas makes insulin, but the insulin made does not work as it should. This condition is called insulin resistance.
ICD-10 contains only:
Diagnosis codes
In ICD-10-CM and ICD-10-PCS these elements are:
Diseases, injuries, surgeries, and procedures, which are grouped into appropriate chapters and sections
Neoplasm Table and a Table of:
Drugs and chemicals
During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of ____, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by ___and the code(s) for the HIV-related illness(es)
During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of O98.7-, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority.
Via natural or artificial opening with percutaneous endoscopic assistance F
Entry of instrumentation THROUGH a natural or artificial external opening to REACH AND VISUALIZE the site of the procedure, AND entry, by PUNCTURE OR MINOR INCISION, of INSTRUMENTATION THROUGH the skin or mucous membrane and any other body layers necessary to AID in the performance of the procedure. Ex: laparoscopic-assisted vaginal hysterectomy
Via natural or artificial opening endoscopic 8
Entry of instrumentation THROUGH a natural or artificial external opening to REACH AND VISUALIZE the site of the procedure. Ex: endoscopic ERCP, hysteroscopy, colonoscopy
Via natural or artificial opening 7
Entry of instrumentation THROUGH a natural or artificial external opening to REACH the site of the procedure. Ex: Foley catheter placement, digital rectal exam
Percutaneous endoscopic 4
Entry, by PUNCTURE OR MINOR INCISION, of instrumentation THROUGH the skin or mucous membrane and/or any other body layers necessary to REACH AND VISUALIZE the site of the procedure. Ex: laparoscopic cholecystectomy; endotracheal intubation
Percutaneous 3
Entry, by PUNCTURE OR MINOR INCISION, of instrumentation THROUGH the skin or mucous membrane and/or any other body layers necessary to REACH the site of the procedure. Ex: liposuction, needle biopsy of liver
What Root Operation is defined as "cutting off a portion of a body part without replacement?"
Excision
Excludes notes ICD-10-CM:
Exclude 1 Exclude 2
7 - Dilation
Expanding an orifice or the lumen of a tubular body part The orifice can be natural or artifically created. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part. Examples: Percutaneous transluminal angioplasty, pyloromyotomy
Improvement and major modifications to ICD-9-CM: Significant improvements in coding primary care encounters,
External causes of injury, mental disorders, neoplasms and preventive health
The clinical modification expands ICD-10 codes to:
Facilitate more precise coding of the clinical diagnoses
For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate ________ code should be assigned.
For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for the myocardial infarction, codes from category _____
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for the myocardial infarction, codes from category ---I21 may continue to be reported.
Unlike ICD-9, ICD-0 does not have a:
Hypertension Table
Three-character categories are used in:
ICD-10-CM
International Classification of Diseases, tenth revision, clinical modification
ICD-10-CM (Developed as a replacement for ICD-9)
ICD-9-CM provides a single type of exclusion note, whereas:
ICD-10-CM has two types of "excludes" notes - each one with a different use
Seven-character codes are used in:
ICD-10-PCS
International Classification of Diseases, Tenth Revision, Procedure Coding System
ICD-10-PCS (Developed as a replacement for ICD-9)
Standardized methodolgy:
ICD-10-PCS should include unique definitions for the term used, with each term having a specific meaning
Number of chapters in ICD-10-CM and ICD-9-CM:
ICD-10: 21 ICD-9: 17
Maximum number of digits/characters in ICD-10-CM and ICD-9-CM:
ICD-10: 7 digits ICD-9: 5 digits
Max number of digits/characters:
ICD-9-CM volume 3: 4 ICD-10-PCS: 7
ICD-10 was needed to:
Include emerging diseases, and more recent medical knowledge; expand new concepts and expand distinctions for mbulatory and managed care encounters
What is found the same in both systems?
Indention pattern and alphabetization rules
ICD-10-PCS is dived into three sections:
Index, Tables, and List of Codes
"Due to"
Indicates a causal relationship. Sometimes the alphabetic index assumes a relationship (e.g. chronic kidney disease and hypertension) and sometimes it is NOT assumed (e.g., hypertension and heart disease).
How is Septis diagnosised and how long until it resolves?
Lab tests or imaging always required Short-term: resolves within days to weeks
K - Map
Locating the route of passage of electrical impulses and/or location functional areas of a body part. Applicable only to cardiac conduction mechanism and the central nervous system. Examples: cardiac mapping, cortical mapping
4 - Creation
Making a new genital structure that does not take over the function of a body part. Used only for sex change operations
Infections resistant to antibiotics in ICD-10 coding
Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.
Describe the three-stage syndrome that starts with sepsis and progressing through_________ and how it is diagnosised.
Many doctors view sepsis as a three-stage syndrome, starting with sepsis and progressing through severe sepsis to septic shock. The goal is to treat sepsis during its early stage, before it becomes more dangerous. Sepsis To be diagnosed with sepsis, you must exhibit at least two of the following symptoms, plus a probable or confirmed infection: Body temperature above 101 F (38.3 C) or below 96.8 F (36 C) Heart rate higher than 90 beats a minute Respiratory rate higher than 20 breaths a minute
"With"
Means "associated with" or "due to"
"And"
Means and/or
Includes notes
Means that the terms listed are included in the category, subcategory, or code
The largest section in ICD-10-PCS is ________.
Medical and Surgical
Intraoperative and Postprocedural Cerebrovascular Accident
Medical record documentation should clearly specify the cause- and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or postprocedural cerebrovascular accident. Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.
X - Transfer
Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part The body part transferred remains connected to its vascular and nervous supply. Examples: Tendon transfer, skin pedicle flap transfer
PCS codes are ________, meaning that each position of character within a code number has a designated meaning or purpose.
Multiaxial
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: makes limited use of
NOS and NEC categories
Negative or inconclusive blood cultures and sepsis diagnosis in ICD-10
Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.
Dummy placeholders ICD-9-CM:
No
Laterality (right vs. left) in ICD-9-CM:
No
Supplemental classification for ICD-10-CM:
No, incorporated into classification
NEC
Not Elsewhere Classifiable: the condition is fully described, but doesn't have its own unique code.
NOS
Not Otherwise Specified: the condition is not sufficiently described to use a more specific code.
Alphanumeric vs. numeric ICD-9-CM:
Numeric, except for V codes and E codes
Full compliance is required for claims submitted for encounters:
On or after October 1, 2014
V - Restriction
Partically closing an orifice or th elumen of a tubular body part. The orifice can be natural or artificially created. Examples: Esophagogastric fundoplication, cervical cerclage
Patients with any known prior diagnosis of an HIV-related illness should be coded to what in ICD-10?
Patients with any known prior diagnosis of an HIV-related illness should be coded to B20. Once a patient has developed an HIV-related illness, the patient should always be assigned code B20 on every subsequent admission/encounter. Patients previously diagnosed with any HIV illness (B20) should never be assigned to R75 or Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.
Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive what codes?
Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of O98.7- and Z21.
Patients with inconclusive HIV serology
Patients with inconclusive HIV serology Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].
Inconclusive laboratory evidence of human immunodeficiency virus [HIV] is coded as ____ in ICd-10.
Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].
Type 2 diabetes
People with Type 2 diabetes produce insulin. However, there is either not enough insulin or it doesn't work properly in the body. When there is not enough insulin or the insulin is not used as it should be, sugar cannot get into the body's cells for use as energy. This causes blood sugar to rise. Type 2 diabetes is most common in people over age 45 who are overweight. Some people with Type 2 diabetes can manage it by controlling their weight, watching their diet, and exercising regularly. Others might also need to take an oral medicine and/or insulin injections.
5 - Destruction
Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent. None of the body part is physically taken out Example: Fulguration of rectal polyp, cautery of skin lesion
CPT Index arranges main terms alphabetically by
Procedure Service Body Site Abbreviation Synonym Eponym - a name or noun formed after a person and some conditions
External X
Procedures performed DIRECTLY ON the skin or mucous membrane AND procedures performed indirectly by the APPLICATION OF EXTERNAL FORCE through the skin or mucous membrane. Ex: resection of tonsils; closed reduction of fracture
D - Extraction
Pulling or stripping out or off all or a portion of a body part by the use of force. The qualifier Diagnostic is used to identify extractions that are biopsies. Examples: Dilation and currettage, vein stripping
M - Reattachment
Putting back in or on all or a portion of a separated body part to its normal location of other suitable location. Vascular circulation and nervous pathways may or may not be reestablished. Examples: reattachment of hand, reattachment of avulsed kidney
H - Insertion
Putting in a nonbiological applicance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. Example: Insertion of radioactive implant, insertion of central venous catheter
R - Replacement
Putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part The body part may have been taken out or replace, or may be taken out, physically eradicated, or rendered nonfunctional during the REPLACEMENT procedure. A REMOVAL procedure is coded for taking out the device used in a previous replacement procedure. Examples: total hip replacement, free skin graft
Y - Transplantation
Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function. Kidney transplant, heart transplant
U - Supplement
Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. The biological material is non-living, or is living and from the same individual. The body part may have been previously replaced, and the SUPPLEMENT procedure is prerformed to physically reinforce and/or augment the function of the replaced body part. Examples: Herniorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement.
________ is restoring a body part to its normal structure.
Repair
Q - Repair
Restoring, to the extent possible, a body part to its normal anatomic structure and function Used only when the method to accomplish the repair is not one of the other root operations. Examples: Colostomy takedown, herniorrhage, suture of laceration
Abstract procedures from the medical record, BEGINNING with PCS definitions of the
Root Operation
The ____________ describes the objective of the procedure.
Root Operations
Character 1 defines the ________ or broad procedure category where the code is found.
Section
what is the definition for "in remission" with psychoactive substance use
Selection of codes for "in remission" for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider's clinical judgment. The appropriate codes for "in remission" are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).
What is Sepsis?
Sepsis is a potentially life-threatening complication of an infection. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. If sepsis progresses to septic shock, blood pressure drops dramatically, which may lead to death.
Septic shock ICD-10 Guidelines
Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.
3 - Control
Stopping or attempting to stop, postprocedural bleeding. The site of the bleeding is coded as an anatomical region and not to a specific body site Example: Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage
C - Extirpation
Taking or cutting out solid matter from a body part. The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. Examples: Thrombectomy, choledocholithotomy, endarterectomy
9 - Drainage
Taking or letting out fluids and/or gases from a body part. The qualifier "diagnostic" is used to identify drainage procedures that are biopsies. Examples: Thoracentesis, incision and drainage
2 - Change
Taking out of off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane. All CHANGE procedures are coded used an EXTERNAL approach Example: Urinary catheter change, gastrostomy tube change
P - Removal
Taking out of off a device from a body part. If a device is taken out a similar device put in without cutting or puncturing the skin or mucous membrance, the procedure is coded to the root operation CHANGE. otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed. Examples: Drainage tube removal, cardiac pacemaker removal
ICD-9-CM and ICD-10-CM are divided into:
The Index and the Tabular List
Alphabetic INdex is dived into two sections:
The Index to Diseases and Injuries and the Index to External Causes
The three-character categories form:
The basis for data tabulation
Incorporated withing the ICD-10-CM is:
The classification of external causes of injury and poisoning and the classification of factors influencing health status and contact with health services
Use Additional Code
The code under which this instruction appears has codable manifestations, which will be sequenced after this code.
Code first
The code under which this instruction appears is caused by another condition, which must be coded first.
"See"
The coder MUST follow the instruction to review the alternative code in order to determine which is correct.
"See Category"
The coder MUST follow the instruction to review the category in order to obtain the correct code.
"See Condition"
The coder may be looking in a main term of a body part, such as "arterial", but should be looking for the diagnosis, such as "thrombosis".
Severe sepsis ICD-10 Guidelines
The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.
Code also
The condition may require more than one code to adequately describe it.
Neither the codes of the ICD-10-CM nor the code titles may be changed except through:
The coordination and Maintenance process overseen jointly by the NCHS and CMS
Tables are reference grids that appear in the alphanumeric order based on which character(s) of the code?
The first three characters
ICD-10-CM was developed under:
The leadership of the NCHS as a replacement for volumes 1 and 2 of ICD-9-CM (diagnosis codes)
The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be
The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, followed by code T38.3X1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).
Multi-axial structure:
The structure of ICD-10-PCS should be multi-axial, with each code character having the same meaning within a specific procedure n across procedure sections, whenever possible
What are the symptoms of diabetes?
The symptoms of diabetes include: Increased thirst Increased hunger (especially after eating) Dry mouth Frequent urination Unexplained weight loss (even though you are eating and feel hungry) Weak, tired feeling Blurred vision Numbness or tingling of the hands or feet Slow-healing sores or cuts Dry and itchy skin (usually in the vaginal or groin area) Frequent yeast infections
Urosepsis
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
Hypertension, Controlled
This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the appropriate code from categories I10-I15, Hypertensive diseases.
NOS (not otherwise specified)
This note is used in the Tabular List and interpreted to mean "unspecified".
Supplemental classification for ICD-9-CM:
V codes and E codes
J - Inspection
Visually and/or manually exploring a body part. Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. Examples: Diagnostic arthroscopy, exploratory laparotomy
Nosocomial infections (hospital aquired infections) should have an additional code of _______
Y95
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only,what is the principal diagnosis coded?
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
What is the primary listed diagnosis when a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications?
When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.
When a patient returns to be informed of his/her HIV test results and the test result is negative, use code ____, Human immunodeficiency virus [HIV] counseling.
When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] counseling. If the results are positive, see previous guidelines and assign codes as appropriate.
When a pregnant woman has a malignant neoplasm
When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.
When additional treatment is required for a primary malignancy previously excised, what should be coded?
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
What happens when the primary malignancy was previously excised in terms of ICD-10 coding?
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.
When should a category Z85, Personal history of malignant neoplasm code be assigned?
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia,how will it be coded?
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).
What is the primary listed diagnosis when an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care?
When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis.
When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy,what code should be sequenced first?
When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced first, followed by the appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the _______ is sequenced first, followed by the code(s) for the _______.
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
Atherosclerotic Coronary Artery Disease and Angina
When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.
What causes Sepsis?
While any type of infection — bacterial, viral or fungal — can lead to sepsis, the most likely varieties include: Pneumonia Abdominal infection Kidney infection Bloodstream infection (bacteremia) The incidence of sepsis appears to be increasing in the United States. The causes of this increase may include: Aging population. Americans are living longer, which is swelling the ranks of the highest risk age group — people older than 65. Drug-resistant bacteria. Many types of bacteria can resist the effects of antibiotics that once killed them. These antibiotic-resistant bacteria are often the root cause of the infections that trigger sepsis. Weakened immune systems. More Americans are living with weakened immune systems, caused by HIV, cancer treatments or transplant drugs.
diverticulosis
abnormal condition of the pouches or sacs in the lining of the intestine known as diverticula
cerebrovascular disease
abnormal non traumatic conditions that affect the cerebral arteries
Accrediting Bureau of Health Education Schools (ABHES)
accredits graduates of an accredited medical assisting program
Commission on Accreditation of Allied Health Education Programs (CAAHEP)
accredits medical assisting programs in both public and private postsecondary institutions throughout the United States
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Is flexible for
adding new codes
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: has the ability to
aggregate codes across all essential components of a procedure
Completeness:
all substantially different procedures should have a unique code
Improvement and major modifications to ICD-9-CM: Expanded distinctions for
ambulatory and managed care encounters
unstable angina
an accelerating, or crescendo, pattern of chest pain that occurs at rest or during mild exertion, typically lasting longer than angina pectoris and not responsive to medication
International Classification of Diseases, Tenth Revision, Clinical Modification
an arrangement of classes or groups of diagnoses and procedures by systemic division
ischemic heart disease
an inadequate supply of blood to the heart caused by an occlusion
hypertension
an increase in systolic pressure, diastolic pressure, or both
colitis
an inflammation of the colon
esophagitis
an inflammation of the esophagus
enteritis
an inflammation of the intestines
dermatitis
an inflammation of the upper layer of the skin
integumentary
covering or outer layer
detachment
cutting off of all or a portion of an extremity
excision
cutting out or off, without replacement, a portion of a body part
open
cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
cholelithiasis
formation or presence of gallstones
there were ____ main objectives in the development of ICD-10-PCS
four: Completeness, expandability, multi-axial structure, & standardized methodology
Conventions retained that are already familiar to users of ICD-9-CM:
instructional notes abbreviations cross-reference notes punctuation marks relational terms "and"
Use Additional Code
instructs the coder to use an additional code to identify the manifestation that is present
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Has
laterality
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
law passed by Congress in 1996 that mandates how paper and electronic health information is cared for and monitored
transitional cell carcinoma
neoplastic cells undergoing malignant changes and confined to the original epithelium site without invading surround tissues; also called carcinoma in situ, non infiltrating carcinoma, noninvasive carcinoma, and pervasive carcinoma
noninvasive carcinoma
neoplastic cells undergoing malignant changes that are confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, non infiltrating carcinoma, carcinoma in situ, and preinvasive carcinoma
preinvasive carcinoma
neoplastic cells undergoing malignant changes that are confined to the original epitheliums site without invading surrounding tissues; also called transitional cell carcinoma, non infiltrating carcinoma, noninvasive carcinoma, and carcinoma in situ
benign tumors
noncancerous growth of cells
nonmalignant tumors
not life-threatening, benign
ICD-10-CM: characters 2-7
numeric or alpha
myocardial infarction (MI)
occurs when there is inadequate blood supply to a section or sections of the heart; also called a heart attack
ICD-10-PCS uses a table structure that:
permits the specification of a large number of codes on a single page in the tabular division
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Ensures that all terminology is
precisely defined and used consistently across all codes
ICD-10-PCS consists of:
procedure codes
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: precisely defines
procedures with detail regarding body part, approach, any device used, and qualifying information
American Medical Technologists (AMT)
professional association for medical technicians
angia pectoris
severe chest pain caused by an insufficient amount of blood reaching the heart
cutane
skin
access location
skin or mucous membranes that can be punctured or cut to reach the site; external orifices such as the mouth, nares of the nose, or a stoma
extracorporeal
something that is outside of the body
Compliance date is based on:
the date of discharge for inpatient claims and the date of service for outpatient claims Date is consistent with the long-standing practice of inpatient facilities using the version of ICD codes in effect on the date of discharge
gastrointestinal (GI) tract
the digestive system
stroke
the disruption in the normal blood supply to the brain; also called a cerebrovascular accident
cecum
the end of the ileum and the start of the large intestine
morphology
the form and structure of neoplastic growth of cells
metastasize
the growing and spreading of cancer to other body parts
phlebitis
the inflammation of a vein
thrombophlebitis
the inflammation of a vein with the formation of a thrombus
endocarditis
the inflammation of the brain
pericarditis
the inflammation of the outer layers of the heart
To build a PCS code, coders assign _________ to each character, based on specific characteristics of the procedure the physician performs.
values
hives
urticaria
ICD-10-PCS improvements and major modifications to ICD-9-CM volume 3: Reflects current
usage of medical terminology and devices
colon
used after a term that is being modified by one or more of the terms following the colon
insulin
used by the body to process glucose
parentheses
used in both the Tabular List and Alphabetic Index. Used around terms providing additional information about the main diagnostic term
NEC (not elsewhere classified)
used in the Alphabetic Index to represent "other specified" when a specific code is not available for a condition the Index directs the coder to the "other specified" code in the Tabular. In the Tabular List, the NEC still means "not elsewhere classifiable" and can be read as "other specified".
Excludes 2
used to signify that the diagnostic terms listed after the note are not part of the condition(s) represented by the code or code block
Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be dominant. • If the left side is affected, the default is non-dominant. • If the right side is affected, the default is dominant.
