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AAPC-CPC-Chapter 3
| Question | Answer |
|---|---|
| What's exluded from the table of Neoplasms: ________, Melanomas and _______ | Lipomas, Merkle cell carcinomas (these are in Alphabetical Index) |
| For most neoplasms begin in _______ then consult table of Neoplasms then tabular list. | Alphabetic index |
| Table of Drugs and Chemicals identify the substances and _____ for adverse effects and ______ | causes, poisonings |
| Index to external causes of Injuries has _____ of accident or incident | type |
| Tabular list has ____ chapters and are different colors | 21 |
| Appendix A is Z codes for long term use of _____ | drugs |
| Appendix B- symbols for _____ character codes | 7th |
| Steps to assign ICD-10 code: first start with main term in the _____, next go to ______ list, then complete code to ____ degree of specificity. | Index, Tabular, highest |
| ICD-10 came into use in WHO and United started in what year? | 1994 |
| Use ICD-10 to clasify diseases and other health problems on many records including ______ | death certificates |
| Alphabetic Index is also called Index to _____ and Injuries | Diseases |
| Requirement to receive payment for services | Medical Necessity |
| Payers require this to determine the need for care: 1. knowledge of the emergent nature or _____ of the pts complaint or condition. 2. All S/S, complaints or background facts describing the _____ for care. 3. Facts must be ______ by med rec. | severity, reason, substantiated |
| Tabular List may have "Includes and Excludes" notes that apply to the ______ chapter. | entire |
| NEC stands for _____ ________ classified | Not Elsewhere |
| NEC used when ICD-10 system does not provide a code specific for the pts _____. | Condition |
| _____ for when provider documented more specific info regaurding the pts condition but there isn't a code to report condition accuarately. | NEC |
| NOS stands for Not _______ specified | Otherwise |
| NOS: unspecified and used only when you _____ the info necessary to code a more _____ diagnosis. | lack, specific |
| _____ codes usually end in 8 or 9 | Other |
| Other codes are used when info in the medical record provides detail for which specific code _____ exist. | doesn't |
| _______ codes usually end in 9 or 0 | Unspecified |
| Unspecified codes are used when info in medical record is ____ available for coding more specifically. | not |
| _______ codes should only be selected if there's no other option! | Unspecified |
| Excludes 1: represents "_____ coded here" and isn't used at the same time as the code above the Exludes 1 note when the 2 diagnosis are ______ | not, related |
| Excludes 2 represents "not ______ here" | included |
| Excludes 2 indicates that the condition excluded is not part of the ______ represented by the code but the pt may have ______ conditions at the same time. | condition, both |
| When excludes 2 appears under a code it is acceptable to use _____ the code and the excluded code together when both conditions exist. | both |
| Excludes 1: only the code for the condition mentioned in excludes 1 note should be assigned as long as there's ____ conficting coding guideline _____ it. | no, preventing |
| Excludes 1 exclude condition rather than ____ being reported together. | codes |
| Excludes 1: make sure to pay attention to specific condition that is _____ and not just the code itself. | excluded |
| Excludes 1 exception when 2 conditions are clearly _____ | unrelated |
| Use additional code: should be used after a primary code if info is available to provide a more _____ picture of the diagnosis | complete |
| Code first: used in the tabular list, indicates _____ codes are needed, and requires the underlying disease be recorded ____ and the manifestation be recorded 2nd | 2, first |
| Eponym: disease or syndrome named after a _____ | Person (example: Lou Gehrig's disease) |
| Essential modifiers: indented ___ spaces and listed in alphabetical order _____ the main term. | 2, below |
| Non essential modifiers: follow the main term and are in _____ | parentheses |
| With can mean with or _____ | due to |
| Default Code is listed _____to a main term | next |
| .- (point dash symbol) stands for code is _____ | incomplete |
| _____ stands for Not Elsewhere Classafiable | NEC |
| NEC: no specific _____ exists | code |
| Supplementary words, in parentheses, do not _____ code assignment. | effect |
| Default Code: represents the condition most _____ associated with main term | commonly |
| 3 character codes represent _____ | category |
| _____ ______ is the disease, illness or condition of the patient | Main term |
| ICD Guideline I.B.1: consult alphabetic index ____ then the tabular list. | first |
| "A" in code stands for _____ | initially |
| If type of diabetes is not in med record the default is _____-Type 2 diabetes mellitus. | E11 |
| When trying to determine the main term it may be helpful to read the ____right to left | diagnosis |
| Outpatient setting: do not code a diagnosis unless it is ____ | certain |
| Inpatient setting: report supected or rule out _____ as if the condition _____ exist. | diagnosis, does (Except HIV, must be confirmed 1st) |
| Multiple coding for same condition: in alphatetic index- codes for both etiology and manifestation of a disease following the sub entry term with the ____ code in brackets. | second |
| Multiple coding for single condition: alphabetic index- assisgn _____ codes in the same sequence in which they appear in the alphabetic index. | both |
| Tabular list notes that indicate when to use more than 1 code: Code ____, Code, if applicable any casual condition 1st, Code ____, use _____ codes | 1st, also, additional |
| When both acute and chronic are documented and there is a separate code for each - report ____ codes | both |
| Chronic conditions treated on an ongoing basis may be coded as ____ times required for treatment | many |
| History of should be coded using ____ code if the history affects pt care or provides the ______ for a pt to seek medical attention. | Z, need |
| Sequelae: _____ effects | late |
| Sequelae is the residual effect after the _____ portion of an illness or injury has terminated. | acute |
| Sequelae: no _____ limit on when it can be used. | time |
| ______ may be apparent early after acute phase or much later (year or more). | Sequelae |
| Sequale is coded according to the nature of the _____ condition of sequelae. | residual |
| Sequelae: _____ codes usually required and the code for the cause may be used as _____ diagnosis when no residual diagnosis is identified. | 2, primary |
| These terms may be used to document a Sequale: due to an _____ injury, due to a ______ illness, | old, previous |
| Sequelae: the code for the acute phase of an illness or injury that leads to the sequela is _____ used with a code for the cause of the sequale. | never |
| Example of causes of Sequala: Malunion due to ____ fracture of ankle, Tramatic arthritis _____ fracture of left wrist. | old, following |
| Can look up Saquelae in _____ | Index |
| There are some instances where the code includes both sequelae and manifestation in one code, for this only _____ code is reported. | one |
| Impending or threatened condition: look up impending or threatened under the _____ term with the condition as the sub term. | main |
| Provider may report 2 different conditions with same diagnosis code: only report the ______ code. | unique |
| Bilateral: the ______ character of the code indicates laterality. | final |
| An ______ side code is available if laterality isn't spceified. | unspecified |
| If no bilateral code is provided assign ______ codes for both left and right. | separate |
| The bilateral code is reprted even if only one side is being ____. | treated |
| Laterality: Ex: pt has bilateral cataracts but is having cataract surgery on one eye- _____ cataract diagnosis code is reported. | bilateral |
| NIH stroke scale, BMI, depth of non pressure chronic ulcers, social determination of health, laterality, pressure ulcer stages, coma scale, blood alcohol level and underimmunization status can be used from any ____ docu & should only be ______ diagnosis. | clinician, secondary |
| If there isn't a _____ in index, code the pts symptoms | syndrome |
| Borderline diagnosis: coded as ______ diagnosis unless there is an index entry of borderline for the classification. | confirmed |
| Hurricane aftermath: code _____ | X37 |
| When no code captures both the chronic and acute nature of the illness code the _____ first then the chronic. | acute |
| Impending: look up "impending/threatening" if there isn't a listing then code the _____ underlying condition not the impending. | existing |
| When looking up conditions remember there is ______ and traumatic. | pathalogical |
| Outpatient: _____ listed diagnosis is used in lieu of principal diagnosis. | first |
| Oupatient: diagnosis is not often established at the the time of _____ encounter/vist. | initial |
| Outpatient: May take 2 or more visits before diagnosis _____ | confirmed |
| Outpatient: codes that describe signs and symptoms as opposed to diagnosis are ok when doctor _____ confirmed diagnosis. | hasn't |
| Circumstances other than disease or injury: Health _____ (Z00-Z99). | Services |
| Health Services: circumstances other than _____ or injury. | disease |
| Health ______ codes EX: follow up after completing treatment for Malignant neoplasm- look up "Examination/follow up (routine)(following)/Malignant neoplasm" Z08 | services |
| Health Services codes: Z00-_____ | Z99 |
| Therapeutic services: first code the _____ for visit/encounter other diagnosies then can be ______. | reason, additional |
| Pre operative Evals only- Z01.81 "Encounter for Pre Procedural Exams" look up ______/ pre-procedural then assign codes for reason for surgery as _____ diagnosis, then any findings of the _____. | Examination, additional, eval |
| Ambulatory surgery is surgery that doesn't require _____ stay. | inpatient |
| ______ surgery you code diagnosis for which surgery was performed. | Ambulatory |
| Ambulatory surgery: if post-op diagnosis is _____ select post-op diagnosis. | different |
| Routine prenatal visits: code from ______ category. | Z34 |
| General exams with abnormal findings: code _____ exam with abnormal findings then abnormal findings are coded. | general |
| Circumstances other than disease or injury: ____ _______ | Health Services (Z00-Z99). |
| When pt has outpatient surgery and develops complications requiring admission, code the reason for the _____ as the primary diagnosis and the complications as ______ diagnosis. | surgery, secondary |
| Guideline _____: report the reason for surgery first even if the surgery is cancelled for contraindications. | IV.A.1 |
| Report reason for surgery 1st even if the surgery is _____ for contraindications then condition found (acute finding) then the code for "cancelled procedure/because of /contraindication" | cancelled |
| Guideline IV.H: code signs and symptoms when dianosis is _____. | uncertain |
| Patient general exam: look up "______ (for)(general)(routine). | examination |
| Guideline IV.P: report 1st the general medical exam then _____ finding. | abnormal |
| Guideline IV.M: Code 1st from Z01.81 category for pt receiving pre-op evals only then code for the condition to describe the _____ for the surgery, then code any _______ r/t pre- op eval. | reason, findings |
| 3 character codes | Rubrics |
| Z codes: describe circumstances or conditions that could _____ pt care. | influence |
| Cyclic neutropenia is coded with D70.4 with Use additional code for any associated: fever (R50.81). Cyclic neutropenia with fever is coded: _____, R50.81 | D70.4 |
| A default code is the code that represents the condition most _____ associated with the main term. | commonly |
| ICD-10 code for essential hypertension: | I10 |
| What is the ICD-10 code for bilat hip pain? | M25.551, M25.552 |
| Guideline I.B.1: the recommended method for using your ICD-10-CM code book is always consult the alphabetic index ______, then refer to the tabular _____ to locate the selected code. | first, list |
| Guideline I.B.8 pt with acute exacerbation of chronic condition, and no single code captures both the chronic and acute nature of the illness, how are the codes sequenced? Code the acute condition _____, followed by the chronic condition. | first |
| Nausea and vomiting code | R11.2 |
| Guideline IV.M: First code for encounter for preprocedure ______, then Code for the condition to describe the reason for the _____ as an additional diagnosis. Next code finding related to the reasson for the pre-op screening | examinations, surgery |
| Guideline IV.A.2: when a pt presents for outpatient surgery and develops complications requiring admission for observation, code the _____ for the surgery as the primary diagnosis and the complications as secondary diagnosis. | reason |
| Guideline IV.A.1: report the reason for surgery as the _____ listed diagnosis even if the surgery is cancelled due to a _______ | first, contraindication |
Created by:
mlovest
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