buck's step-by-step ch 1-2 Flashcards by Heather Murray

Q

A code that reports more than one diagnosis with one code is a ____ code.
or
A single ICD-10-CM code used to classify two diagnoses?

A

combination code

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Q

Terms in the Index are listed by _____

A

symptoms, encounter, complication

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Q

T or F
ICD-10 CM contains 17 chapters

A

False

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Q

T or F
All main terms in the ICD-10-CM Index are in bold

A

True

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Q

T or F
ICD-10-CM codes are alphanumeric

A

True

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Q

directs coder to use Tabular lists for additional information

A

See catagory

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Q

explicit directions to look elsewhere

A

see

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Q

defines and gives insturctions

A

notes

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Q

terms indented under main terms, considered essential modifiers

A

subterm

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Q

directs coder to look under another term if all information is not located under the first term

A

see also

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Q

Indicates two conditions are included in the code. Interpreted to mean “associated with” or “due to.” Presumes a causal relationship between two conditions

A

with

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Q

terms in parentheses or following main terms; they may or may not be essential

A

modifiers

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Q

NEC

A

Not elsewhere classifiable

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Q

NOS

A

Not otherwise specified

the equivalent of “unspecified.” It is used when the information at hand does not permit a more specific code assignment (The coder should query the physician for more specific information so that a more specific code assignment can be made.)

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Q

Enclose synonyms, alternate wording, or explanatory phrases. They identify manifestation codes

A

[Brackets]

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Q

Enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code

A

(Parentheses)

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Q

-terms within the parentheses used to clarify the diagnosis but do not affect code assignment

A

Non-essential modifiers

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Q

used in the tabular list after an incomplete term that needs one or more of the modifiers following the colon to make it assignable to a given category

A

Colon :

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Q

And is interpreted to mean?

A

either “and” or “or”

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Q

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

A

Includes

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Q

NOT code here

purely excludes
A type ___ Excludes note is a pure excludes. It means ‘NOT CODED HERE!’ An Excludes __ note indicates that the code excluded should never be used at the same time as the code above the Excludes ___ note. An Excludes ___ is used when twoconditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

A

Excludes 1

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Q

Not included here.

Conditions excluded in not part of the condition represented by the code, but a patient may have both conditions at the same time.

A type ____excludes note represents ‘Not included here’. An excludes___note indicates that the condition excluded is not partof the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes__ noteappears under a code it is acceptable to use both the code and the excluded code together.

A

Excludes 2

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Q

Code first-

A

The code is sequenced first

indicates a manifestation due to underlying etiology

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Q

Additional code-

A

An additional code be required to fully describe the condition

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instructs that two codes may be required to fully describe the condition, but the sequencing of the two codes is discretionary

Code also

What does ICD-10-CM stand for?

International Classification of Diseases, 10th edition, Clinical Modification manual

Coding language explaines ____ happened during a pt. visit and ____ it happened.

What Why

treatment plans include:

procedures, services, and treatments that improve the pts. current condition or support good health.

A procedure is ______?

an action or series of actions. ex... surgery is a procedure

Services include ________?

counseling, educating, or advice

treatment is ___________?

the application of healthcare services ex.... chemotherapy or acupuncture

Why? Diagnosis / ? What? Procedure / ?

why / ICD-10-CM what / CPT

What does CPT stand for?

Current Procedure Terminology

The I-10 was originally issued in 1993 by_____?

WHO - World Health Organization

The country that uses the ICD-10-AM is?

Australia

The I-10 designed for the classification of patient _______and_______?

Morbidity (sickness) and Mortality (death)

The CM in ICD-10-CM stand for ?

Clinical Modification

List four of the six reasons why diagnosis codes are used today.

1. Facilitate payment for health services 2. Evaluate patients' use of health care facilities (utilization patterns) 3. Study health care cost 4. Research the quality of health care 5. Predict health care trends 6. Plan for future health care needs

The I-10 is used to translate what descriptive information into alphanumeric codes?

verbal or narrative

4 groups who deal with coding principles and practices:

1 CMS - Centers for Medicare and Medicaid Services (formerly HCFA) 2. NCHS - National Center for Health Statistics 3. AHIMA - American Health Information Management Association 4. AHA -American Hospital Association

A group of three-character categories that represent a group of conditions or related conditions.

Block

A three-character category code represents a single condition or disease.

Category

A four-character subcategory code provides more information or specificity as compared to the three-character code in terms or the cause, site, or manifestation of the condition

Subcategory

A five- to seven-character subclassification code adds even more information and specificity to a conditions description. You must assign the additional characters if they are available.

Subclassification

____ ____ is used for all codes and titles in the Tabular List.

Bold type

______ ______ is used for all exclusion notes and to identify those codes that are not usually sequenced as the first-listed diagnosis. Cannot be assigned as a first-listed diagnosis because they always follow another code. Sequenced according to specific coding instructions in the Tabular List, such as “Code first . . . ”.

Italicized type

indicate condition most commonly associated with the main terms

Default codes

For codes less than 6 characters that require a 7th character, a placeholder ___ is assigned for all characters less than 6

place holder X

What department in the United States is responsible for developing the procedure classification entitled the ICD-10-PCS (Procedure Coding System)?

CMS Centers for Medicare and Medicaid Services

ICD-10 is used in outpatient settings to establish ________ __________

Medical necessity

The three levels of indentation in the Andes are main terms, sub terms, and ________?

carryover lines

A three-character ________ code represents a single condition or disease, format that is indicated each chapter of the ICD-10-CM

Category

When two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition, what note is used in ICD-10-CM?

Excludes 1

An ICD-10- CM code that can never be sequenced as the principal or primary diagnosis?

Italicized code

Brackets are used to identify ________ codes when used in the Alphabetic Index

Manifestation Codes

Formally known as the Health Care Financing Administration (HCFA)?

Centers for Medicare and Medicaid Services or CMS

The main division in the ICD-10-CM manual?

Chapter

Chapters are divided into _____and then ________.

Sections and then Catagories

Section is a gourd of ____ alpha-digit categories that include a group of related conditions

3 alpha-digits categories (M20-M25, other joint disorders)

________ represents a single condition/disease ____ characters

Category 3

The term "first diagnosis" is used in lieu of __________ diagnosis in an outpatient setting

Principle

T/F: When reporting the first listed diagnosis, the coding conventions and specific quidelines of the ICD-10-CM take precedence over the outpatient guidelines

True

The 4 sections of the Alphabetic Index

Index to Diseases and Injuries Neoplasms Table of Drugs and Chemicals External Cause of injuries

Three indents levels

Main Term (Bold Print) Subterms Carryover lines

The _____ is responsible for maintaining the International Classification of Diseases manual.

World Health Organization

Which is Not one of the purposes of the International classification of Diseases, 10th Revision, Clinical Modifications (ICD-10-CM): Patient illness Death Information Statistical purposes Evaluate patient morbidity

Evaluate patient morbidity

The ICD-10-CM manual is used to assign _____ codes.

Diagnosis

T/F: Coders use the coding language "International Classification of diseases, 10th Edition, Clinical Modifications" to provide information about the WHY the patient is being seen.

True.

T/F: ICD-10-CM provides information about WHAT the provider did to help the patient.

False

To find a diagnosis code, you start by looking the main term up in the ____ index

Alphabetic

The _____ index contains ICD-10-CM codes with descriptions. Alphabetic, Tabular, Numeric, or Conditions

Tabular

An ____ _ note means "NOT CODED HERE"

Excludes1

An _____ _ note means "NOT INCLUDED HERE"

Excludes2

The character ____ is used as a placeholder in ICDS-10-CM.

X