Chap 6 Basic ICD-10 Coding Steps

Question 1

three basic steps for locating codes to be assigned.

Answer 1

Locate the main term in the Alphabetic Index. Search for subterms, notes, or cross-references.

– Verify the code number in the Tabular List.

– Assign the verified code or codes.

Question 2

Alphabetic Index of Diseases and Injuries and the Index to External Causes

Answer 2

include entries for main terms (diseases, conditions, or injuries) and subterms (site, type, or etiology), the Neoplasm Table, and the Table of Drugs and Chemicals

Question 3

Tabular List

Answer 3

contains categories, subcategories, and valid codes

Question 4

You can’t begin to code unless you have determined

Answer 4

the principal diagnosis and other reportable diagnoses from the medical record.

Question 5

Step 1.Locate the main term in the Alphabetic Index.

Answer 5

Review subterms and nonessential modifiers related to the main term.
Follow any cross-reference instructions.
Refer to any notes in the Alphabetic Index.
A dash (-) at the end of an Index entry indicates that additional characters are required.

Question 6

Step 2.Verify the code number in the Tabular List.

Answer 6

Read the code title.
Read and follow any instructional notes. Refer to other codes as instructed.
Determine whether an additional character must be added.
Determine laterality (right or left) and any applicable extensions.

Question 7

Step 3.Assign the verified code or codes.

Answer 7

It is imperative that these steps be followed without exception; the condition to be coded must first be located in the Alphabetic Index and then verified in the Tabular List. Relying on memory or using only the Index or Tabular List may lead to incorrect code assignment.

Question 8

If a main term cannot be located,

Answer 8

tconsider a synonym, an eponym, or another alternative term.

Question 9

Once the main term is located,

Answer 9

a search should be made of subterms, notes, or cross-references.

Subterms provide more specific information of many types and must be checked carefully, following all the rules of alphabetizatio

Question 10

The main term code entry should not be assigned until all subterm possibilities have been exhausted.

Answer 10

During this process, it may be necessary to refer again to the medical record to determine whether any additional information is available to permit assignment of a more specific code.

Question 11

If a subterm cannot be located,

Answer 11

the nonessential modifiers following the main term should be reviewed to see whether the subterm may be included there. If not, alternative terms should be considered.